Provider Demographics
NPI:1366794562
Name:MILWAUKEE HEALTH CARE, LLC
Entity type:Organization
Organization Name:MILWAUKEE HEALTH CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-535-6700
Mailing Address - Street 1:2 BOURBON ST
Mailing Address - Street 2:WEST PEABODY EXECUTIVE CENTER, SUITE 200
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1384
Mailing Address - Country:US
Mailing Address - Phone:978-535-6700
Mailing Address - Fax:978-535-6701
Practice Address - Street 1:9350 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1714
Practice Address - Country:US
Practice Address - Phone:414-438-4360
Practice Address - Fax:414-464-3622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2821314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52-5367OtherMEDICARE PROVIDER NUMBER
WI100033186Medicaid