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General NPI Number Information
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NPI Number | 1649090168
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Entity Type | Organization
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Legal Business Name | 5 GOODMEN COMMUNITY CARE GROUP HOME LLC
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Dates
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Enumeration Date | 10/10/2024
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Last Update Date | 10/10/2024
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Provider Practice Location Address
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Address Line | 942 N 29TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53208-3406
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Country | US
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Telephone | 414-988-5321
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Fax |
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Provider Business Mailing Address
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Address Line | 942 N 29TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53208-3406
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Country | US
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Telephone | 414-988-5321
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Fax |
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Authorized Official
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Title or Position | COO
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Name | MR. GEORGE WEAVER
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Credential | B.A DEGREE
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Telephone | 414-309-2740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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