Provider Demographics
NPI:1598920035
Name:CRC WISCONSIN RD LLC
Entity Type:Organization
Organization Name:CRC WISCONSIN RD LLC
Other - Org Name:BURKWOOD TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:615 OLD MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-6959
Mailing Address - Country:US
Mailing Address - Phone:715-386-6125
Mailing Address - Fax:715-381-0158
Practice Address - Street 1:615 OLD MILL ROAD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-6959
Practice Address - Country:US
Practice Address - Phone:715-386-6125
Practice Address - Fax:715-381-0158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRC WISCONSIN RD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-24
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12365324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility