MEDICARE: POTTERS HOUSE PNCC SERVICES

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1790350908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTTERS HOUSE PNCC SERVICES

Provider Business Mailing Address
First Line	:	824 S 18TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-1125
Country	:	US
Telephone Number	:	414-419-1025
Fax Number	:	414-810-0523

Provider Business Practice Location Address
First Line	:	2110 W NATIONAL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-1159
Country	:	US
Telephone Number	:	414-940-8564
Fax Number	:	414-810-0523

Authorized Official
Title or Position	:	OWNER
Name	:	MS. DEQUANA BOSTICK
Credential	:
Telephone Number	:	414-419-1025

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/21/2021

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