MEDICARE: KINGLY COMMUNITY RESOURCE CENTER

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	:	1881133627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGLY COMMUNITY RESOURCE CENTER

Provider Business Mailing Address
First Line	:	4200 N HOLTON ST
Second Line	:	SUITE 110
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1008
Country	:	US
Telephone Number	:	414-899-6838
Fax Number	:	414-509-7412

Provider Business Practice Location Address
First Line	:	4200 N HOLTON ST
Second Line	:	SUITE 110
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1008
Country	:	US
Telephone Number	:	414-899-6838
Fax Number	:	414-509-7412

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT C RANDOLPH
Credential	:
Telephone Number	:	414-899-6838

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	02/13/2017

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Directions to “KINGLY COMMUNITY RESOURCE CENTER ” Practice Location

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