Healthcare Provider Details

I. General information

NPI: 1902085624
Provider Name (Legal Business Name): VISTA CARE WISCONSIN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 ERIE AVE STE 201
SHEBOYGAN WI
53081-4060
US

IV. Provider business mailing address

708 ERIE AVE STE 201
SHEBOYGAN WI
53081-4060
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-0826
  • Fax: 920-457-2207
Mailing address:
  • Phone: 920-457-0826
  • Fax: 920-457-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number11183
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number9340
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TIMOTHY A. FREY
Title or Position: PRESIDENT
Credential:
Phone: 920-457-0826