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General NPI Number Information
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NPI Number | 1619530474
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Entity Type | Organization
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Legal Business Name | FIRSTLIGHT OF WEST BEND, WI
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | W175N11163 STONEWOOD DR STE 208
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City | GERMANTOWN
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State | WI
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Zip | 53022-6502
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Country | US
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Telephone | 262-299-5989
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Fax |
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Provider Business Mailing Address
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Address Line | 310 S MILWAUKEE ST
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City | THERESA
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State | WI
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Zip | 53091-9663
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Country | US
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Telephone | 920-276-2019
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KELLY RENEE GENGLER
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Credential |
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Telephone | 920-979-5640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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