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General NPI Number Information
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NPI Number | 1306398110
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Entity Type | Organization
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Legal Business Name | MED GROUP HOME HEALTH CARE AGENCY LLC
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Dates
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Enumeration Date | 10/27/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 11053 N TOWNE SQUARE RD
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City | MEQUON
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State | WI
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Zip | 53092-5051
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Country | US
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Telephone | 414-755-2103
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Fax | 414-755-1784
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Provider Business Mailing Address
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Address Line | 11053 N TOWNE SQUARE RD
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City | MEQUON
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State | WI
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Zip | 53092-5051
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Country | US
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Telephone | 414-755-2103
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Fax | 414-755-1784
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Authorized Official
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Title or Position | OWNER
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Name | DARIKO MEKVABISHVILI
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Credential |
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Telephone | 414-755-2103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1194
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License Number State | WI
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