Healthcare Provider Details

I. General information

NPI: 1780850594
Provider Name (Legal Business Name): MILWAUKEE HEALTH SERVICES SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 N RICHARDS ST
MILWAUKEE WI
53212-1673
US

IV. Provider business mailing address

6183 PASEO DEL NORTE STE 200
CARLSBAD CA
92011-1155
US

V. Phone/Fax

Practice location:
  • Phone: 414-967-7012
  • Fax: 414-967-7020
Mailing address:
  • Phone: 855-259-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number1643
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1643
License Number StateWI

VIII. Authorized Official

Name: BRIAN PHILLIP FARLEY
Title or Position: VP & SECRETARY
Credential:
Phone: 615-861-6000