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General NPI Number Information
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NPI Number | 1043874985
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Entity Type | Organization
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Legal Business Name | PLEASANTVILLE HOME CARE AGENCY
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Dates
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Enumeration Date | 04/25/2019
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Last Update Date | 04/25/2019
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Provider Practice Location Address
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Address Line | 4200 N HOLTON ST STE 100
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City | MILWAUKEE
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State | WI
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Zip | 53212-1064
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Country | US
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Telephone | 414-909-0296
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Fax | 414-962-4003
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Provider Business Mailing Address
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Address Line | 4200 N HOLTON ST STE 100
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City | MILWAUKEE
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State | WI
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Zip | 53212-1064
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Country | US
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Telephone | 414-909-0296
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Fax | 414-962-4003
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEITH MARTIN JR.
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Credential |
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Telephone | 414-759-6059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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