Healthcare Provider Details

I. General information

NPI: 1669705240
Provider Name (Legal Business Name): OCONOMOWOC DEVELOPMENT TRAINING CENTER LL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3222 N. SILVER CEDAR RD.
OCONOMOWOC WI
53066
US

IV. Provider business mailing address

PO BOX 278
DOUSMAN WI
53118
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-5515
  • Fax: 262-569-9962
Mailing address:
  • Phone: 262-569-5515
  • Fax: 262-569-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateWI

VIII. Authorized Official

Name: MS. M. DEBORAH FRISK
Title or Position: VICE PRESIDENT
Credential: MSW
Phone: 262-569-5515