MEDICARE: MKE CLIA SOLUTIONS

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	291U00000X	Clinical Medical Laboratory
2	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1871244699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MKE CLIA SOLUTIONS

Provider Business Mailing Address
First Line	:	4911 W GOOD HOPE RD STE 103
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-4840
Country	:	US
Telephone Number	:	414-885-3709
Fax Number	:	414-306-6426

Provider Business Practice Location Address
First Line	:	4911 W GOOD HOPE RD STE 103
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-4840
Country	:	US
Telephone Number	:	414-885-3709
Fax Number	:	414-306-6426

Authorized Official
Title or Position	:	CEO
Name	:	MS. FELICIA LATORIA ALSTORK
Credential	:	RN
Telephone Number	:	414-885-3709

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	03/18/2022

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