Healthcare Provider Details

I. General information

NPI: 1487820346
Provider Name (Legal Business Name): EAU CLAIRE ACADEMY HC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N DEWEY ST
EAU CLAIRE WI
54703-3218
US

IV. Provider business mailing address

550 N DEWEY ST
EAU CLAIRE WI
54703-3218
US

V. Phone/Fax

Practice location:
  • Phone: 715-834-6681
  • Fax: 715-834-9954
Mailing address:
  • Phone: 715-834-6681
  • Fax: 715-834-9954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number560002
License Number StateWI

VIII. Authorized Official

Name: MR. CHARLES LEE ALBRENT
Title or Position: EXECUTIVE DIRECTOR
Credential: M.P.A.
Phone: 715-834-6681