Healthcare Provider Details

I. General information

NPI: 1326221557
Provider Name (Legal Business Name): TABOMA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 WASHINGTON AVE SUITE 290
RACINE WI
53406-4232
US

IV. Provider business mailing address

4701 WASHINGTON AVE SUITE 290
RACINE WI
53406-4232
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-7767
  • Fax: 262-637-7764
Mailing address:
  • Phone: 262-637-7767
  • Fax: 262-637-7764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number1082
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1082
License Number StateWI

VIII. Authorized Official

Name: MR. JACK LOUKS
Title or Position: PRESIDENT
Credential:
Phone: 262-637-7767