Healthcare Provider Details

I. General information

NPI: 1649364365
Provider Name (Legal Business Name): MILWAUKEE VA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 WEST NATIONAL AVENUE
MILWAUKEE WI
53295
US

IV. Provider business mailing address

5000 WEST NATIONAL AVENUE
MILWAUKEE WI
53295
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 414-384-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateWI

VIII. Authorized Official

Name: MR. ANTHONY WILBERT CARR
Title or Position: ADDICTION THERAPIST
Credential:
Phone: 414-384-2000