MEDICARE: HOPE HOUSING OF SHAWANO COUNTY AND WISCONSIN-USA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	WI
2	302F00000X	Exclusive Provider Organization	WI
3	347C00000X	Private Vehicle	WI
4	374U00000X	Home Health Aide	WI
5	253Z00000X	In Home Supportive Care Agency
6	251X00000X	Supports Brokerage Agency

General Provider Information

NPI Number	:	1528497799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOPE HOUSING OF SHAWANO COUNTY AND WISCONSIN-USA

Provider Business Mailing Address
First Line	:	2153 N 36TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1406
Country	:	US
Telephone Number	:	414-553-5247
Fax Number	:

Provider Business Practice Location Address
First Line	:	2153 N 36TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1406
Country	:	US
Telephone Number	:	414-553-5247
Fax Number	:

Authorized Official
Title or Position	:	EX DIRECTOR
Name	:	MR. DANIEL CHARLES CROWLEY I
Credential	:	STREET SMART
Telephone Number	:	414-553-5247

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	01/03/2014

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