=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942605670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHU ADULT FAMILY CARE HOME II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2014
-----------------------------------------------------
Last Update Date | 10/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2824 N 59TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-466-8930
-----------------------------------------------------
Fax | 414-873-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3070 N 55TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-1563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-466-8930
-----------------------------------------------------
Fax | 414-873-4501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAMES MWANGI METHU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-466-8930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 0015250
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------