MEDICARE: FAMILYLIVINGLLC

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	3104A0625X	Assisted Living Facility (Mental Illness)	0013975	WI

General Provider Information

NPI Number	:	1720344237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILYLIVINGLLC

Provider Business Mailing Address
First Line	:	9120 N 94TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-1705
Country	:	US
Telephone Number	:	414-354-7004
Fax Number	:

Provider Business Practice Location Address
First Line	:	9120 N 94TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-1705
Country	:	US
Telephone Number	:	414-354-7004
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. GWENDOLYN LACHELLE JONES
Credential	:
Telephone Number	:	414-354-7004

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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