Provider Demographics
NPI:1326631730
Name:KINGSMEN YOUTH SERVICES INC
Entity Type:Organization
Organization Name:KINGSMEN YOUTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-725-5228
Mailing Address - Street 1:8543 W FAIRY CHASM DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-1809
Mailing Address - Country:US
Mailing Address - Phone:262-725-5228
Mailing Address - Fax:262-661-7719
Practice Address - Street 1:1037 W MCKINLEY AVE # 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2530
Practice Address - Country:US
Practice Address - Phone:262-725-5228
Practice Address - Fax:262-661-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health