Provider Demographics
NPI:1790837128
Name:MILWAUKEE HEALTH SERVICES SYSTEM, LLC
Entity Type:Organization
Organization Name:MILWAUKEE HEALTH SERVICES SYSTEM, LLC
Other - Org Name:10TH STREET COMPREHENSIVE TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:6183 PASEO DEL NORTE, STE 200
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1155
Mailing Address - Country:US
Mailing Address - Phone:855-259-2288
Mailing Address - Fax:
Practice Address - Street 1:4800 S. 10TH STREET
Practice Address - Street 2:UNIT 1
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2412
Practice Address - Country:US
Practice Address - Phone:414-744-5370
Practice Address - Fax:414-744-9052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRC HEALTH GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-17
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16442084P0802X, 261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42030200Medicaid
WIE5700183Medicare UPIN