Basic Information
| Provider Information | |||||||||
| NPI: | 1710967104 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECOVER HEALTH OF WISCONSIN, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVEANNA HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704648000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 330 S EXECUTIVE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627828292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STRANGE | ||||||||
| AuthorizedOfficialFirstName: | HARMON | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4704648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RECOVER HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100061976 | 05 | WI | MEDICAID |