NPIMap

Organization Active NPI

Southport Healthcare LLC

Doing business as Kenosha Visiting Nurse Association

  • Community Health Clinic/Center
  • Kenosha, WI
National Provider Identifier
1740906874
Registry record updated Jun 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
SOUTHPORT HEALTHCARE LLC
Doing business as
Kenosha Visiting Nurse Association
Practice address
600 52ND St Ste 300
Kenosha, WI 53140-3423
Phone
(262) 656-8400
NPI assigned
Oct 19, 2022
Last updated
Jun 6, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 6, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amber L Tueller
Title
Secretary
Phone
(208) 207-2726

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X Primary

Addresses

Primary practice location

600 52ND St Ste 300
Kenosha, WI 53140-3423

Mailing address

600 52ND St Ste 300
Kenosha, WI 53140-3423
Phone (262) 656-8400

Other names 1

  • Kenosha Visiting Nurse Association Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221130000174 WI Part B Supplier - Mass Immunization (Roster Biller Only) 3678941531 Practice locations: Kenosha, WI

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Kenosha Visiting Nurse Association3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1666137600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749168000000",
    "number": "1740906874",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 52ND ST STE 300",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531403423",
            "telephone_number": "262-656-8400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 52ND ST STE 300",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531403423",
            "telephone_number": "262-656-8400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHPORT HEALTHCARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-19",
        "last_updated": "2025-06-06",
        "certification_date": "2025-06-06",
        "status": "A",
        "authorized_official_last_name": "TUELLER",
        "authorized_official_first_name": "AMBER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "208-207-2726"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kenosha Visiting Nurse Association",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kenosha, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.