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General NPI Number Information
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NPI Number | 1609147958
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Entity Type | Organization
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Legal Business Name | MED GROUP HOME HEALTH CARE AGENCY
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Dates
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Enumeration Date | 01/18/2012
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Last Update Date | 09/25/2014
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Provider Practice Location Address
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Address Line | 11402 N PORT WASHINGTON RD SUITE 214 B
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City | MEQUON
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State | WI
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Zip | 53092-3447
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Country | US
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Telephone | 414-755-2009
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Fax | 414-755-1767
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Provider Business Mailing Address
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Address Line | 2111 N DR MARTIN LUTHER KING DR
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City | MILWAUKEE
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State | WI
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Zip | 53212-3101
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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 | PRESIDENT
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Name | DARIKO MEKVABISHVILI
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Credential |
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Telephone | 414-745-3146
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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 |
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License Number State |
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