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General NPI Number Information
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NPI Number | 1366264624
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Entity Type | Individual
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Provider Name | ROENA ANGELA WATERS ADULT FAMILY HOME
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Gender | Female
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Dates
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Enumeration Date | 10/28/2024
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 4910 63RD AVE
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City | KENOSHA
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State | WI
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Zip | 53144-1709
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Country | US
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Telephone | 262-351-5955
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Fax | 262-222-2399
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Provider Business Mailing Address
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Address Line | 4910 63RD AVE
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City | KENOSHA
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State | WI
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Zip | 53144-1709
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Country | US
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Telephone | 262-351-5955
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Fax | 262-222-2399
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 0019382
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License Number State | WI
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