Basic Information
| Provider Information | |||||||||
| NPI: | 1043250558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IN HOME HEALTH LLC | ||||||||
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| OtherOrganizationName: | PROMEDICA HOSPICE (KENOSHA) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192547841 | ||||||||
| FaxNumber: | 4192526448 | ||||||||
| Practice Location | |||||||||
| Address1: | 10200 W INNOVATION DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 251G00000X | 2003 | WI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 43189100 | 05 | WI | MEDICAID |