Provider Demographics
NPI:1275700437
Name:ST. AEMILIAN LAKESIDE
Entity Type:Organization
Organization Name:ST. AEMILIAN LAKESIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY ASSURANCE SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ALSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-463-1880
Mailing Address - Street 1:8901 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8901 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1706
Practice Address - Country:US
Practice Address - Phone:414-463-1880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1586121322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children