=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992185631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARE FOR ALL AGES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2015
-----------------------------------------------------
Last Update Date | 06/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1308 S NORWOOD AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-432-8119
-----------------------------------------------------
Fax | 920-432-0060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1308 S NORWOOD AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-432-8119
-----------------------------------------------------
Fax | 920-432-0060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | RACHEL CHVALA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-432-8119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 0015405
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------