MEDICARE: SAM'S HPUSE

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	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1295140036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAM'S HPUSE

Provider Business Mailing Address
First Line	:	PO BOX 13201
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-0201
Country	:	US
Telephone Number	:	262-262-5271
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 N 26TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53233-2528
Country	:	US
Telephone Number	:	262-262-5271
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DIANE SANDER-GRAY
Credential	:
Telephone Number	:	12625271282

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	06/30/2014

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