=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215427612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOLTKE PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2018
-----------------------------------------------------
Last Update Date | 05/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6741 W MOLTKE AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-1354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-739-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 511693
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53203-0291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-739-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. MARY WOODS
-----------------------------------------------------
Credential | MSM
-----------------------------------------------------
Telephone | 414-739-2105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 177F00000X
-----------------------------------------------------
Taxonomy Name | Lodging Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------