Provider Demographics
NPI:1528437498
Name:ETERNITY HOMECARE, INC.
Entity type:Organization
Organization Name:ETERNITY HOMECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS LIAISON
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:KLINE
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:608-251-2273
Mailing Address - Street 1:1402 GREENWAY CROSS
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3181
Mailing Address - Country:US
Mailing Address - Phone:608-251-2273
Mailing Address - Fax:866-748-3232
Practice Address - Street 1:1402 GREENWAY CROSS
Practice Address - Street 2:SUITE 101
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-3181
Practice Address - Country:US
Practice Address - Phone:608-251-2273
Practice Address - Fax:866-748-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302R00000X, 253Z00000X, 302F00000X, 251B00000X, 251F00000X, 251300000X, 251T00000X, 251E00000X, 251J00000X
WI100014484251B00000X, 251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No253Z00000XAgenciesIn Home Supportive Care
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No251B00000XAgenciesCase Management
No251F00000XAgenciesHome Infusion
No251300000XAgenciesLocal Education Agency (LEA)
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770996100OtherINDIVIDUAL NPI
WI100014484Medicaid