Provider Demographics
NPI:1487820346
Name:EAU CLAIRE ACADEMY HC
Entity Type:Organization
Organization Name:EAU CLAIRE ACADEMY HC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ALBRENT
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:715-834-6681
Mailing Address - Street 1:550 N DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-3218
Mailing Address - Country:US
Mailing Address - Phone:715-834-6681
Mailing Address - Fax:715-834-9954
Practice Address - Street 1:550 N DEWEY ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-3218
Practice Address - Country:US
Practice Address - Phone:715-834-6681
Practice Address - Fax:715-834-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI560002322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43015000Medicaid