1861615874 NPI number — WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861615874 NPI number — WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861615874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3732 W WISCONSIN AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53208-3153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-290-0400
Provider Business Mailing Address Fax Number:
414-271-4605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
949 N 9TH ST
Provider Second Line Business Practice Location Address:
ROOM 131E
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53233-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-223-1329
Provider Business Practice Location Address Fax Number:
414-223-1836
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATZER
Authorized Official First Name:
HOLLIS
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
414-290-0418

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  2133-800 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32920400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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