=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063141307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARE CONNECTION HEALTH SOLUTIONS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2022
-----------------------------------------------------
Last Update Date | 06/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 BISHOPS WAY STE 152
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-6271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-355-5525
-----------------------------------------------------
Fax | 414-240-3595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13851
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53213-0851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-355-5525
-----------------------------------------------------
Fax | 414-240-3595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARTAVIA STANFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-355-5525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------