Basic Information
| Provider Information | |||||||||
| NPI: | 1205318102 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUTREACH COMMUNITY HEALTH CENTERS, INC. | ||||||||
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| OtherOrganizationName: | ST ELIZABETH ANN SETON DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2018 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | SANDER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 4147276320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PDYD | ||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.