MEDICARE: EASTER SEALS SOUTHEAST WISCONSIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care

General Provider Information

NPI Number	:	1073839528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS SOUTHEAST WISCONSIN

Provider Business Mailing Address
First Line	:	1016 MILWAUKEE AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-2006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 MILWAUKEE AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-2006
Country	:	US
Telephone Number	:	414-571-5566
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT GLOWACKI
Credential	:
Telephone Number	:	414-571-5566

Provider Enumeration Date	:	04/08/2010
Last Update Date	:	04/08/2010

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Directions to “EASTER SEALS SOUTHEAST WISCONSIN ” Practice Location

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