=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437936093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUINTESSENTIAL HEARTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2023
-----------------------------------------------------
Last Update Date | 09/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2812 N 5TH ST #102
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-350-8845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4249 N 38TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-350-8845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWENER
-----------------------------------------------------
Name | QUINNETTE BOGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-350-8845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------