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General NPI Number Information
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NPI Number | 1710304878
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Entity Type | Organization
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Legal Business Name | EXODUS TRANSITIONAL CARE FACILITY INC.
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Dates
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Enumeration Date | 03/26/2014
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 1421 FOND DU LAC AVE
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City | KEWASKUM
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State | WI
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Zip | 53040-9136
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Country | US
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Telephone | 626-626-4166
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Fax | 262-626-8431
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Provider Business Mailing Address
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Address Line | 1421 FOND DU LAC AVE
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City | KEWASKUM
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State | WI
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Zip | 53040-9136
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Country | US
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Telephone | 262-626-4166
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Fax | 262-626-8431
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Authorized Official
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Title or Position | CLINICAL SUPERVISOR/DIRECTOR
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Name | MRS. CHERYL E COLWIN
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Credential |
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Telephone | 262-626-4166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 2598
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License Number State | WI
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