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General NPI Number Information
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NPI Number | 1831439264
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Entity Type | Organization
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Legal Business Name | DESTANI'S CHILD MEDICAL DAYCARE, INC
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Dates
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Enumeration Date | 02/21/2013
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Last Update Date | 02/21/2013
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Provider Practice Location Address
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Address Line | 3062 N 58TH ST SUITE 200
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City | MILWAUKEE
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State | WI
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Zip | 53210-1545
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Country | US
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Telephone | 414-217-2495
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Fax | 414-445-3893
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Provider Business Mailing Address
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Address Line | 3062 N 58TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53210-1545
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Country | US
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Telephone | 141-217-2495
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Fax | 414-445-3893
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. JANICE M GORDEN
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Credential | RN
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Telephone | 414-217-2495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 109525
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License Number State | WI
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