Basic Information
| Provider Information | |||||||||
| NPI: | 1275056632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUTREACH COMMUNITY HEALTH CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHCARE FOR THE HOMELESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532063328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149649018 | ||||||||
| FaxNumber: | 4147276328 | ||||||||
| Practice Location | |||||||||
| Address1: | 9120 W HAMPTON AVE STE 119 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532254960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2017 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | PALMER | ||||||||
| AuthorizedOfficialFirstName: | CONSTANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 4147276320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 42219000 | 05 | WI | MEDICAID |