MEDICARE: LOYALTY FOOTPRINTS OF LIFE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	385HR2055X	Child Mental Illness Respite Care
2	174200000X	Meals Provider
3	253Z00000X	In Home Supportive Care Agency
4	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
5	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
6	347C00000X	Private Vehicle
7	385H00000X	Respite Care

General Provider Information

NPI Number	:	1154019479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOYALTY FOOTPRINTS OF LIFE

Provider Business Mailing Address
First Line	:	2742 N 34TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-2517
Country	:	US
Telephone Number	:	414-702-7058
Fax Number	:

Provider Business Practice Location Address
First Line	:	2742 N 34TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-2517
Country	:	US
Telephone Number	:	414-702-7058
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MS. TAMARA VIRGHES
Credential	:
Telephone Number	:	414-702-7058

Provider Enumeration Date	:	04/25/2023
Last Update Date	:	04/25/2023

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