Provider Demographics
NPI:1447609029
Name:SHEBOYGAN COMPREHENSIVE TREATMENT CENTER
Entity Type:Organization
Organization Name:SHEBOYGAN COMPREHENSIVE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAUCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-458-6527
Mailing Address - Street 1:W1781 PUDDLEFORT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CALVARY
Mailing Address - State:WI
Mailing Address - Zip Code:53057-9714
Mailing Address - Country:US
Mailing Address - Phone:920-904-3533
Mailing Address - Fax:
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-458-6527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16934-130251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI101YA0400XMedicaid