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General NPI Number Information
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NPI Number | 1306587167
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Entity Type | Organization
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Legal Business Name | RETRAC ENTERPRISES INC
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 4117 N GREEN BAY AVE
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City | MILWAUKEE
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State | WI
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Zip | 53209-7019
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Country | US
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Telephone | 414-433-0780
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Fax | 414-433-5780
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Provider Business Mailing Address
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Address Line | 4117 N GREEN BAY AVE
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City | MILWAUKEE
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State | WI
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Zip | 53209-7019
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Country | US
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Telephone | 414-218-8670
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMBER ELLIS
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Credential | PHYSICIAN ASSISTANT
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Telephone | 414-218-8670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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