Healthcare Provider Details

I. General information

NPI: 1306435144
Provider Name (Legal Business Name): MATT TALBOT RECOVERY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 SAINT CLAIR ST
RACINE WI
53402-3007
US

IV. Provider business mailing address

2819 W HIGHLAND BLVD
MILWAUKEE WI
53208-3217
US

V. Phone/Fax

Practice location:
  • Phone: 414-939-7145
  • Fax: 414-321-5935
Mailing address:
  • Phone: 414-939-7145
  • Fax: 414-321-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KARL RAJANI
Title or Position: CEO
Credential:
Phone: 414-301-6381