MEDICARE: WILLAMINA BANKSTON

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1174404834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLAMINA BANKSTON

Provider Business Mailing Address
First Line	:	2517 W HALSEY AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-2969
Country	:	US
Telephone Number	:	262-497-6382
Fax Number	:

Provider Business Practice Location Address
First Line	:	2517 W HALSEY AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-2969
Country	:	US
Telephone Number	:	262-497-6382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2025
Last Update Date	:	09/09/2025

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Directions to “ WILLAMINA BANKSTON ” Practice Location

Language	Start Address	Practice Location

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