Provider Demographics
NPI:1770996100
Name:THAO, VANG (ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:VANG
Middle Name:
Last Name:THAO
Suffix:
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100014484374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014484Medicaid