MEDICARE: WHITES RESIDENTIAL TREATMENT & CLINICAL SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	2665	WI

General Provider Information

NPI Number	:	1821326455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITES RESIDENTIAL TREATMENT & CLINICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	6400 W CAPITOL DR
Second Line	:	SUITE 212
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2156
Country	:	US
Telephone Number	:	414-536-7098
Fax Number	:	414-536-7106

Provider Business Practice Location Address
First Line	:	4020 W BURLEIGH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1817
Country	:	US
Telephone Number	:	414-445-7288
Fax Number	:	414-445-7708

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. LANELL WHITE
Credential	:	CCS
Telephone Number	:	414-536-7098

Provider Enumeration Date	:	11/19/2009
Last Update Date	:	11/19/2009

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