MEDICARE: LICENSED TO CARE

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	311Z00000X	Custodial Care Facility	303906-031	WI
2	311500000X	Alzheimer Center (Dementia Center)	303906-031	WI

General Provider Information

NPI Number	:	1164729877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICENSED TO CARE

Provider Business Mailing Address
First Line	:	5846 N 68TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-1808
Country	:	US
Telephone Number	:	414-462-9111
Fax Number	:

Provider Business Practice Location Address
First Line	:	5846 N 68TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-1808
Country	:	US
Telephone Number	:	414-462-9111
Fax Number	:

Authorized Official
Title or Position	:	LPN
Name	:	MS. NATASHA NICOLE BLAIR
Credential	:
Telephone Number	:	414-462-9111

Provider Enumeration Date	:	02/15/2011
Last Update Date	:	02/15/2011

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Directions to “LICENSED TO CARE ” Practice Location

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