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General NPI Number Information
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NPI Number | 1619265105
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Entity Type | Organization
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Legal Business Name | PROSPECT CONGREGATE HOUSING, INC.
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Dates
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Enumeration Date | 07/18/2011
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Last Update Date | 07/18/2011
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Provider Practice Location Address
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Address Line | 1400 N PROSPECT AVE
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City | MILWAUKEE
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State | WI
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Zip | 53202-3043
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Country | US
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Telephone | 414-289-9600
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Fax | 414-277-8861
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Provider Business Mailing Address
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Address Line | 1414 N PROSPECT AVE
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City | MILWAUKEE
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State | WI
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Zip | 53202-3018
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Country | US
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Telephone | 414-277-8847
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Fax | 414-276-4828
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | GAIL BOEREMA
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Credential | CFO
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Telephone | 414-277-8815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 10313
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License Number State | WI
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