Basic Information
| Provider Information | |||||||||
| NPI: | 1790837128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILWAUKEE HEALTH SERVICES SYSTEM, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 10TH STREET COMPREHENSIVE TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6183 PASEO DEL NORTE, STE 200 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4800 S. 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147445370 | ||||||||
| FaxNumber: | 4147449052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRC HEALTH GROUP | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | 1644 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 261QM2800X | 1644 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 42030200 | 05 | WI | MEDICAID |