MEDICARE: DIRECT CARE SUPPORTIVE SERVICE 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1861978181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRECT CARE SUPPORTIVE SERVICE LLC

Provider Business Mailing Address
First Line	:	11805 W HAMPTON AVE STE 103C
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3612
Country	:	US
Telephone Number	:	414-213-3966
Fax Number	:	414-755-7676

Provider Business Practice Location Address
First Line	:	11805 W HAMPTON AVE STE 103C
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3612
Country	:	US
Telephone Number	:	414-213-3966
Fax Number	:	414-755-7676

Authorized Official
Title or Position	:	OWNER/ADMIN
Name	:	DETRA FERGUSON-CALLAHAN
Credential	:
Telephone Number	:	414-213-3966

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	07/19/2018

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