MEDICARE: A NURTURING HOME AWAY FROM HOME INC.

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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1083077713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A NURTURING HOME AWAY FROM HOME INC.

Provider Business Mailing Address
First Line	:	8225 N 107TH
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-5008
Country	:	US
Telephone Number	:	414-870-2207
Fax Number	:

Provider Business Practice Location Address
First Line	:	8225 N 107TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-2517
Country	:	US
Telephone Number	:	414-870-2207
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARY A MITCHELL
Credential	:
Telephone Number	:	414-870-2207

Provider Enumeration Date	:	03/31/2016
Last Update Date	:	03/31/2016

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