Healthcare Provider Details

I. General information

NPI: 1891182473
Provider Name (Legal Business Name): WESTERN REGION RECOVERY & WELLNESS CONSORTIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N BRIDGE ST RM 305
CHIPPEWA FALLS WI
54729-1845
US

IV. Provider business mailing address

711 N BRIDGE ST RM 305
CHIPPEWA FALLS WI
54729-1845
US

V. Phone/Fax

Practice location:
  • Phone: 715-726-7787
  • Fax: 715-726-7736
Mailing address:
  • Phone: 715-726-7787
  • Fax: 715-726-7736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3065
License Number StateWI

VIII. Authorized Official

Name: LARRY WINTER
Title or Position: DIRECTOR
Credential:
Phone: 715-726-7788