MEDICARE: PRESTIGIOUS ACADEMY INC

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	LZ-0000183	WI

General Provider Information

NPI Number	:	1902313299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGIOUS ACADEMY INC

Provider Business Mailing Address
First Line	:	2624 N 16TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-2014
Country	:	US
Telephone Number	:	414-265-8181
Fax Number	:	414-265-7998

Provider Business Practice Location Address
First Line	:	2624 N 16TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-2014
Country	:	US
Telephone Number	:	414-265-8181
Fax Number	:	414-265-7998

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. EB COLEMAN
Credential	:
Telephone Number	:	414-702-3792

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	03/17/2018

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