Healthcare Provider Details

I. General information

NPI: 1174877591
Provider Name (Legal Business Name): PRESTIGE ADULT DAY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8048 N 76TH ST
MILWAUKEE WI
53223-3202
US

IV. Provider business mailing address

2924 W ROOSEVELT DR
MILWAUKEE WI
53216-1838
US

V. Phone/Fax

Practice location:
  • Phone: 414-343-9616
  • Fax:
Mailing address:
  • Phone: 414-343-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number176207-30
License Number StateWI

VIII. Authorized Official

Name: MS. LAKISHA H KING
Title or Position: DIRECTOR
Credential: RN
Phone: 414-343-9616