MEDICARE: ETHEREAL MUSE COLLECTIVE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1962335059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHEREAL MUSE COLLECTIVE LLC

Provider Business Mailing Address
First Line	:	4212 W HAWTHORNE TRACE RD APT 206
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-1023
Country	:	US
Telephone Number	:	414-236-2745
Fax Number	:

Provider Business Practice Location Address
First Line	:	4212 W HAWTHORNE TRACE RD APT 206
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-1023
Country	:	US
Telephone Number	:	414-236-2745
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LASHEENIA EVANS
Credential	:	CNA
Telephone Number	:	414-236-2745

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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