=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104649144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TMJ FAMILY HOME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6475 N 87TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53224-5437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-897-3457
-----------------------------------------------------
Fax | 414-206-0256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6475 N 87TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53224-5437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-897-3457
-----------------------------------------------------
Fax | 414-206-0256
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TYNISHA MCWRIGHT
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 414-897-3457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------