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General NPI Number Information
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NPI Number | 1477660132
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Entity Type | Organization
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Legal Business Name | MID AMERICA HEALTHCARE CORP OF WISCONSIN
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 02/10/2012
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Provider Practice Location Address
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Address Line | 811 N HAWLEY RD STE 201
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City | MILWAUKEE
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State | WI
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Zip | 53213-3289
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Country | US
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Telephone | 414-578-2961
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Fax | 414-578-2962
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Provider Business Mailing Address
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Address Line | 811 N HAWLEY RD
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City | MILWAUKEE
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State | WI
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Zip | 53213-3289
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Country | US
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Telephone | 414-578-2961
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Fax | 414-578-2962
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Authorized Official
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Title or Position | ADMINISTRATOR/ DON
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Name | MS. SOUPHALACK KHAMMYVONG
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Credential |
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Telephone | 414-578-2961
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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 | 527256
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License Number State | WI
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