Organization
LIFE ENHANCEMENT SUPPORTIVE SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TONYETTA L ROSS BS, SACIT (EXECUTIVE DIRECTOR)
(414) 690-0672
Entity
Organization
Contact information
Practice address
3537 N 57TH ST, MILWAUKEE, WI 53216-2819
(414) 690-0672
Mailing address
3537 N 57TH ST, MILWAUKEE, WI 53216-2819
(414) 690-0672
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12088599
CAQH
WI
Enumeration date
05/20/2013
Last updated
05/20/2013
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