Provider Demographics
NPI:1992676902
Name:FULLY LOADED LLC
Entity type:Organization
Organization Name:FULLY LOADED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAVONNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-527-7490
Mailing Address - Street 1:1810 W FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5721
Mailing Address - Country:US
Mailing Address - Phone:262-527-7490
Mailing Address - Fax:
Practice Address - Street 1:1810 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5721
Practice Address - Country:US
Practice Address - Phone:262-527-7490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No253Z00000XAgenciesIn Home Supportive Care