Basic Information
| Provider Information | |||||||||
| NPI: | 1285187179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER'S SHORE CLINIC CTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | LATEKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4149677006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 227113 | WI | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 100056280 | 05 | WI | MEDICAID |