Basic Information
| Provider Information | |||||||||
| NPI: | 1881942845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILWAUKEE HEALTH SERVICES SYSTEM, LLC | ||||||||
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| OtherOrganizationName: | WAUSAU 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544035475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158453637 | ||||||||
| FaxNumber: | 7158451977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2012 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADIA HEALTHCARE COMPANY, INC. | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2408 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 100055685 | 05 | WI | MEDICAID |