Provider Demographics
NPI:1154750511
Name:MED GROUP ADULT DAY CARE OF WI
Entity type:Organization
Organization Name:MED GROUP ADULT DAY CARE OF WI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKVABISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-755-0558
Mailing Address - Street 1:11402 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3447
Mailing Address - Country:US
Mailing Address - Phone:414-755-0558
Mailing Address - Fax:414-755-1763
Practice Address - Street 1:6572 S LOVERS LANE RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-1209
Practice Address - Country:US
Practice Address - Phone:414-755-0558
Practice Address - Fax:414-755-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0014565261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care