Healthcare Provider Details

I. General information

NPI: 1245628817
Provider Name (Legal Business Name): FOREVER FREE SUBSTANCE ABUSE AND MENTAL HEATH TREAMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S LAYTON BLVD
MILWAUKEE WI
53215-1224
US

IV. Provider business mailing address

724 S LAYTON BLVD
MILWAUKEE WI
53215-1224
US

V. Phone/Fax

Practice location:
  • Phone: 414-383-8533
  • Fax:
Mailing address:
  • Phone: 414-383-8533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number3059
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-617-1801