Basic Information
| Provider Information | |||||||||
| NPI: | 1861615874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3732 W WISCONSIN AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532083153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142900400 | ||||||||
| FaxNumber: | 4142714605 | ||||||||
| Practice Location | |||||||||
| Address1: | 949 N 9TH ST | ||||||||
| Address2: | ROOM 131E | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142231329 | ||||||||
| FaxNumber: | 4142231836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | PATZER | ||||||||
| AuthorizedOfficialFirstName: | HOLLIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4142900418 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 2133-800 | WI | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 32920400 | 05 | WI | MEDICAID |