Basic Information
| Provider Information | |||||||||
| NPI: | 1144684697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILWAUKEE HEALTH SERVICES SYSTEM, LLC | ||||||||
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| OtherOrganizationName: | NORTH WEST WISCONSIN COMPREHENSIVE TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6183 PASEO DEL NORTE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3440 OAKWOOD HILLS PKWY | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547017698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152142525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADIA HEALTHCARE | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 100059526 | 05 | WI | MEDICAID |