Healthcare Provider Details

I. General information

NPI: 1720344237
Provider Name (Legal Business Name): FAMILYLIVINGLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 N 94TH ST
MILWAUKEE WI
53224-1705
US

IV. Provider business mailing address

9120 N 94TH ST
MILWAUKEE WI
53224-1705
US

V. Phone/Fax

Practice location:
  • Phone: 414-354-7004
  • Fax:
Mailing address:
  • Phone: 414-354-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number0013975
License Number StateWI

VIII. Authorized Official

Name: MRS. GWENDOLYN LACHELLE JONES
Title or Position: DIRECTOR
Credential:
Phone: 414-354-7004