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General NPI Number Information
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NPI Number | 1093262891
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Entity Type | Organization
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Legal Business Name | RIVER'S SHORE CLINIC CTC
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Dates
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Enumeration Date | 09/09/2016
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Last Update Date | 09/09/2016
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Provider Practice Location Address
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Address Line | 3707 N RICHARDS ST
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City | MILWAUKEE
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State | WI
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Zip | 53212-1673
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Country | US
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Telephone | 414-967-7006
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Fax |
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Provider Business Mailing Address
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Address Line | 8048 N CELINA ST
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City | MILWAUKEE
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State | WI
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Zip | 53224-2904
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Country | US
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Telephone | 414-750-6525
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | LAPIKA WASHINGTON
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Credential | MS, CSAC, ICS
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Telephone | 414-967-7006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 312890-31
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License Number State | WI
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