Healthcare Provider Details

I. General information

NPI: 1790178952
Provider Name (Legal Business Name): SACRED GARDEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W FOND DU LAC AVE
MILWAUKEE WI
53216-3527
US

IV. Provider business mailing address

4201 W FOND DU LAC AVE
MILWAUKEE WI
53216-3527
US

V. Phone/Fax

Practice location:
  • Phone: 414-871-1040
  • Fax: 414-871-2419
Mailing address:
  • Phone: 414-871-1040
  • Fax: 414-871-2419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA SWIFT
Title or Position: VICE PRESIDENT
Credential:
Phone: 414-871-1040