Healthcare Provider Details

I. General information

NPI: 1912157223
Provider Name (Legal Business Name): SUPPORTIVE HOME LIVING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W BROADWAY STE 2
WAUKESHA WI
53186-4848
US

IV. Provider business mailing address

250 W BROADWAY STE 2
WAUKESHA WI
53186-4848
US

V. Phone/Fax

Practice location:
  • Phone: 262-544-0687
  • Fax: 262-544-0715
Mailing address:
  • Phone: 262-544-0687
  • Fax: 262-544-0715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY KINGSTON
Title or Position: CEO
Credential:
Phone: 262-544-0687