Provider Demographics
NPI:1114196854
Name:LAD LAKE, INC.
Entity Type:Organization
Organization Name:LAD LAKE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ERDMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-965-2131
Mailing Address - Street 1:W350S1401 WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-9020
Mailing Address - Country:US
Mailing Address - Phone:262-965-2131
Mailing Address - Fax:
Practice Address - Street 1:W350S1401 WATERVILLE RD
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118-9020
Practice Address - Country:US
Practice Address - Phone:262-965-2131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINONE320800000X
WI265001322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness