=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467609776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED COMMUNITY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2008
-----------------------------------------------------
Last Update Date | 08/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 S 6TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53204-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-643-8530
-----------------------------------------------------
Fax | 414-647-8602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 S 6TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53204-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-643-8530
-----------------------------------------------------
Fax | 414-647-8602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF HUMAN SERVICES
-----------------------------------------------------
Name | MRS. CINDY KAY SUSZEK
-----------------------------------------------------
Credential | MS SAP CTS CEAP
-----------------------------------------------------
Telephone | 414-649-1922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 1657
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 1949
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------