Provider Demographics
NPI:1275707010
Name:LAC COURTE OREILLES DAY TREATMENT PROGRAM
Entity Type:Organization
Organization Name:LAC COURTE OREILLES DAY TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIVING HAWK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-638-5100
Mailing Address - Street 1:13380 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-638-5100
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:13380 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-638-5100
Practice Address - Fax:715-634-6107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC COURTE OREILLES COMMUNITY HEALTH CTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1486261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42135921Medicaid