Healthcare Provider Details

I. General information

NPI: 1962312165
Provider Name (Legal Business Name): ELANDIS SUPPORTIVE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8117 W SCRANTON PL
MILWAUKEE WI
53218-3547
US

IV. Provider business mailing address

8117 W SCRANTON PL
MILWAUKEE WI
53218-3547
US

V. Phone/Fax

Practice location:
  • Phone: 414-294-9123
  • Fax:
Mailing address:
  • Phone: 414-294-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: OLYMPIA JOHNSON
Title or Position: OWNER
Credential:
Phone: 414-294-9123