Provider Demographics
NPI:1821281577
Name:COULEE YOUTH CENTERS, INC.
Entity Type:Organization
Organization Name:COULEE YOUTH CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:EIDE
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:608-782-7152
Mailing Address - Street 1:231 COPELAND AVE
Mailing Address - Street 2:P.O.BOX 1836
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-3086
Mailing Address - Country:US
Mailing Address - Phone:608-782-7152
Mailing Address - Fax:608-785-1241
Practice Address - Street 1:231 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3086
Practice Address - Country:US
Practice Address - Phone:608-782-7152
Practice Address - Fax:608-785-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1241251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42164300Medicaid