Healthcare Provider Details

I. General information

NPI: 1336205855
Provider Name (Legal Business Name): MATCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 N 1ST ST
MILWAUKEE WI
53212-2406
US

IV. Provider business mailing address

2902 N 1ST ST
MILWAUKEE WI
53212-2406
US

V. Phone/Fax

Practice location:
  • Phone: 414-372-0739
  • Fax: 414-372-0739
Mailing address:
  • Phone: 414-372-0739
  • Fax: 414-372-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number9374
License Number StateWI

VIII. Authorized Official

Name: MS. MERRY KYLES
Title or Position: OWNER
Credential:
Phone: 414-372-0739