MEDICARE: MS. LASHARAI TAZA RUPERT

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1790129591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LASHARAI TAZA RUPERT

Provider Business Mailing Address
First Line	:	5252 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3502
Country	:	US
Telephone Number	:	414-350-1291
Fax Number	:

Provider Business Practice Location Address
First Line	:	5252 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3502
Country	:	US
Telephone Number	:	414-350-1291
Fax Number	:

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

Provider Enumeration Date	:	04/23/2013
Last Update Date	:	04/23/2013

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