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General NPI Number Information
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NPI Number | 1154750511
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Entity Type | Organization
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Legal Business Name | MED GROUP ADULT DAY CARE OF WI
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 6572 S LOVERS LANE RD
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City | FRANKLIN
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State | WI
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Zip | 53132-1209
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Country | US
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Telephone | 414-755-0558
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Fax | 414-755-2470
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Provider Business Mailing Address
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Address Line | 11402 N PORT WASHINGTON RD SUITE 215
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City | MEQUON
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State | WI
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Zip | 53092-3447
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Country | US
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Telephone | 414-755-0558
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Fax | 414-755-1763
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Authorized Official
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Title or Position | PRESIDENT
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Name | DARIKO MEKVABISHVILI
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Credential |
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Telephone | 414-755-0558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 0014565
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License Number State | WI
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