=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003360777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALCARE ADULT FAMILY HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2016
-----------------------------------------------------
Last Update Date | 08/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3912 N 67TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-841-1654
-----------------------------------------------------
Fax | 414-402-8273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3912 N 67TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-861-1654
-----------------------------------------------------
Fax | 414-204-8273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RICHARD A WALKER III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-841-1654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 0015921
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------