Provider Demographics
NPI:1568440998
Name:OCONOMOWOC HOME HEALTH CARE, LLC
Entity type:Organization
Organization Name:OCONOMOWOC HOME HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SUMMERS
Authorized Official - Last Name:MACNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-569-5520
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-0278
Mailing Address - Country:US
Mailing Address - Phone:262-569-5520
Mailing Address - Fax:262-569-6339
Practice Address - Street 1:1746 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4830
Practice Address - Country:US
Practice Address - Phone:262-569-5520
Practice Address - Fax:262-569-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1025251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41537600Medicaid
WI1025OtherHOME HEALTH LICENSE
WI52-7286Medicare ID - Type UnspecifiedMEDICARE HOME HEALTH AGEN