Provider Demographics
NPI:1114415908
Name:IRIS HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:IRIS HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNZELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-420-9088
Mailing Address - Street 1:255 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4832
Mailing Address - Country:US
Mailing Address - Phone:262-420-9088
Mailing Address - Fax:
Practice Address - Street 1:260 S ELM GROVE RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6522
Practice Address - Country:US
Practice Address - Phone:971-334-3150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTAX ID NUMBER