MEDICARE: SACRED KRUMBS 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1861075343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED KRUMBS LLC

Provider Business Mailing Address
First Line	:	3601 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3008
Country	:	US
Telephone Number	:	414-719-0338
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3008
Country	:	US
Telephone Number	:	414-719-0338
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LYNETT HUDSON
Credential	:
Telephone Number	:	414-719-0338

Provider Enumeration Date	:	05/03/2021
Last Update Date	:	05/03/2021

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Directions to “SACRED KRUMBS LLC ” Practice Location

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