Healthcare Provider Details

I. General information

NPI: 1427332501
Provider Name (Legal Business Name): INNOVATIVE RECOVERY NETWORK OF WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 W NATIONAL AVE
MILWAUKEE WI
53204-2114
US

IV. Provider business mailing address

1314 W NATIONAL AVE
MILWAUKEE WI
53204-2114
US

V. Phone/Fax

Practice location:
  • Phone: 414-383-4432
  • Fax: 414-383-4482
Mailing address:
  • Phone: 414-383-4432
  • Fax: 414-383-4482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2961
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONALD HEGEL
Title or Position: PRESIDENT
Credential:
Phone: 414-383-4432