Organization
MID AMERICA HEALTHCARE CORP OF WISCONSIN
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SOUPHALACK KHAMMYVONG (ADMINISTRATOR/ DON)
(414) 578-2961
Entity
Organization
Contact information
Practice address
811 N HAWLEY RD, STE 201, MILWAUKEE, WI 53213-3289
(414) 578-2961
(414) 578-2962
Mailing address
811 N HAWLEY RD, MILWAUKEE, WI 53213-3289
(414) 578-2961
(414) 578-2962
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
Primary
527256
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43107100
—
WI
Enumeration date
08/25/2006
Last updated
02/10/2012
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