Basic Information
| Provider Information | |||||||||
| NPI: | 1346599727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MJ CARE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2448 S 102ND ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1800776701 | ||||||||
| FaxNumber: | 1800350424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 BUTTS AVE | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546602405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723241 | ||||||||
| FaxNumber: | 6083723250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | DONOVAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6083435663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | P.T.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 1907-19 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.