Basic Information
| Provider Information | |||||||||
| NPI: | 1902804586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILWAUKEE CATHOLIC HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142204610 | ||||||||
| FaxNumber: | 4142208495 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142204610 | ||||||||
| FaxNumber: | 4142208495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 11/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | DESAI | ||||||||
| AuthorizedOfficialFirstName: | ROHINI | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4142208468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3213 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20178800 | 05 | WI | MEDICAID |