Healthcare Provider Details

I. General information

NPI: 1528330198
Provider Name (Legal Business Name): HERITAGE STAFFING CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2012
Last Update Date: 01/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N MILWAUKEE ST
MILWAUKEE WI
53202-5885
US

IV. Provider business mailing address

316 N MILWAUKEE ST
MILWAUKEE WI
53202-5885
US

V. Phone/Fax

Practice location:
  • Phone: 414-615-0665
  • Fax: 888-389-9031
Mailing address:
  • Phone: 414-615-0665
  • Fax: 888-389-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number1393-019
License Number StateWI

VIII. Authorized Official

Name: TOM PUCCIO
Title or Position: STAFFER
Credential:
Phone: 414-615-0665