Basic Information
| Provider Information | |||||||||
| NPI: | 1992939383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAU CLAIRE METRO TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 N OXFORD AVE | ||||||||
| Address2: | BOX 4 | ||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547035184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158341078 | ||||||||
| FaxNumber: | 7158341218 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N OXFORD AVE | ||||||||
| Address2: | BOX 4 | ||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547035184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158341078 | ||||||||
| FaxNumber: | 7158341218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | FRANCE | ||||||||
| AuthorizedOfficialFirstName: | DESIREE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7158341078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SACIT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 15699130 | WI | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 15699130 | 01 | WI | STATE OF WI DEPT. OF REG. AND LICENSING | OTHER |