=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134883200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SATORI HOUSE RECOVERY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 4TH AVE
-----------------------------------------------------
City | BARABOO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53913-2175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-433-7329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 OAK CREST AVE
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-335-5933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JAKE EDWARD NIESEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-335-5933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------