Healthcare Provider Details

I. General information

NPI: 1639446172
Provider Name (Legal Business Name): PROFESSIONAL HOME CARE PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10152 8TH AVE
PLEASANT PRAIRIE WI
53158-5413
US

IV. Provider business mailing address

10152 8TH AVE
PLEASANT PRAIRIE WI
53158
US

V. Phone/Fax

Practice location:
  • Phone: 262-942-8484
  • Fax:
Mailing address:
  • Phone: 262-942-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number307458-31
License Number StateWI

VIII. Authorized Official

Name: ANZHELA ANDREICHYK
Title or Position: LPN
Credential: VENT CERTIFIED
Phone: 262-942-8484