Organization
TRI-STAR RESIDENCE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KOUA F THAO ADMINISTRATOR (ADMINISTRATOR)
(414) 248-9239
Entity
Organization
Contact information
Practice address
7504 W RUBY AVE, MILWAUKEE, WI 53218-5458
(414) 248-9239
Mailing address
7504 W RUBY AVE, MILWAUKEE, WI 53218-5458
(414) 248-9239
Taxonomy
Speciality
Code
Description
License number
State
253Z00000X
In Home Supportive Care Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100014873
—
WI
Enumeration date
05/20/2015
Last updated
05/20/2015
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