Healthcare Provider Details

I. General information

NPI: 1881085793
Provider Name (Legal Business Name): HORIZON HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2015
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GOOLD ST
RACINE WI
53402-4567
US

IV. Provider business mailing address

4650 S HOWELL AVE
MILWAUKEE WI
53207-5906
US

V. Phone/Fax

Practice location:
  • Phone: 414-376-5577
  • Fax: 414-376-5577
Mailing address:
  • Phone: 414-376-5577
  • Fax: 414-376-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARREN MATAVKA
Title or Position: VICE PRESIDENT
Credential:
Phone: 414-376-5577