Healthcare Provider Details

I. General information

NPI: 1043554090
Provider Name (Legal Business Name): RASHADA ADULT FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4083 N MONTREAL ST
MILWAUKEE WI
53216-1754
US

IV. Provider business mailing address

4083 N MONTREAL ST
MILWAUKEE WI
53216-1754
US

V. Phone/Fax

Practice location:
  • Phone: 414-840-3049
  • Fax: 414-442-7105
Mailing address:
  • Phone: 414-840-3049
  • Fax: 414-442-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number0013901
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number0013901
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0013901
License Number StateWI

VIII. Authorized Official

Name: MISS KAMILAH RASHADA
Title or Position: OWNER
Credential:
Phone: 414-840-3049