=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275767485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MHS CONVENIENT CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2009
-----------------------------------------------------
Last Update Date | 11/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4061 N 54TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-372-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2555 N MARTIN LUTHER KING DR
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-372-8080
-----------------------------------------------------
Fax | 414-372-7425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | FRAN BOLDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-372-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Nurse Practitioner
-----------------------------------------------------
License Number | 6282-800
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------