Provider Demographics
NPI:1447018817
Name:STATEWIDE GROUP HOMES LLC
Entity type:Organization
Organization Name:STATEWIDE GROUP HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:HASSAN
Authorized Official - Last Name:ABDILLAHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-297-0139
Mailing Address - Street 1:2412 S GREENVIEW ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2412 S GREENVIEW ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4831
Practice Address - Country:US
Practice Address - Phone:920-214-9159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care