MEDICARE: OUR HOME SWEET HOME LLC

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	:	1508415894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR HOME SWEET HOME LLC

Provider Business Mailing Address
First Line	:	4101 N MONTREAL ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1740
Country	:	US
Telephone Number	:	414-400-1717
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 N MONTREAL ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1740
Country	:	US
Telephone Number	:	414-455-3092
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	TELENA A. NASH
Credential	:
Telephone Number	:	414-400-1717

Provider Enumeration Date	:	09/09/2019
Last Update Date	:	11/02/2021

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