Basic Information
| Provider Information | |||||||||
| NPI: | 1609209394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WISCONSIN LUTHERAN CHLD AND FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHRISTIAN FAMILY SOLUTIONS HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623455530 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Practice Location | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623455530 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 08/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POLINSKE | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF IN-HOME CARE PROGRAMS | ||||||||
| AuthorizedOfficialTelephone: | 2623455567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.