Provider Demographics
NPI:1073407599
Name:HERITAGE ON HAMPTON ASSISTED LIVING FACILITY LLC
Entity type:Organization
Organization Name:HERITAGE ON HAMPTON ASSISTED LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-803-7493
Mailing Address - Street 1:11118 W MEINECKE AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1248
Mailing Address - Country:US
Mailing Address - Phone:414-803-7493
Mailing Address - Fax:262-364-2048
Practice Address - Street 1:4615 W HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-5236
Practice Address - Country:US
Practice Address - Phone:414-803-7493
Practice Address - Fax:262-364-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-07
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility