Provider Demographics
NPI:1285187179
Name:RIVER'S SHORE CLINIC CTC
Entity Type:Organization
Organization Name:RIVER'S SHORE CLINIC CTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-967-7006
Mailing Address - Street 1:3707 N RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1673
Mailing Address - Country:US
Mailing Address - Phone:414-967-7006
Mailing Address - Fax:
Practice Address - Street 1:3707 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1673
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI227113324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100056280Medicaid