Basic Information
| Provider Information | |||||||||
| NPI: | 1316908908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MJCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2725 S MOORLAND RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531513720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143292500 | ||||||||
| FaxNumber: | 4143292501 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142204610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | BEISSER | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4143292429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 41808300 | 05 | WI | MEDICAID | 41807900 | 05 | WI | MEDICAID |