MEDICARE: TEE'S DIRECT CARE 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1932062155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEE'S DIRECT CARE LLC

Provider Business Mailing Address
First Line	:	7101 N GREEN BAY AVE STE 7
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-2800
Country	:	US
Telephone Number	:	414-236-5660
Fax Number	:	414-755-7676

Provider Business Practice Location Address
First Line	:	6755 N 55TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-5911
Country	:	US
Telephone Number	:	414-393-3006
Fax Number	:	414-236-5261

Authorized Official
Title or Position	:	CEO
Name	:	DETRA EVON FERGUSON
Credential	:
Telephone Number	:	414-213-3966

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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