Provider Demographics
NPI:1821241464
Name:SKY RESIDENTIAL SERVICES, INC
Entity Type:Organization
Organization Name:SKY RESIDENTIAL SERVICES, INC
Other - Org Name:BROOKSIDE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-916-2710
Mailing Address - Street 1:N94W20846 SCHLEI RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-1127
Mailing Address - Country:US
Mailing Address - Phone:414-916-2710
Mailing Address - Fax:
Practice Address - Street 1:2405 S BROOKSIDE PKWY
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-2905
Practice Address - Country:US
Practice Address - Phone:414-916-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIDSL293320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities