Provider Demographics
NPI:1902386055
Name:ISLANDS OF BRILLIANCE
Entity Type:Organization
Organization Name:ISLANDS OF BRILLIANCE
Other - Org Name:ISLANDS OF BRILLIANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-670-7134
Mailing Address - Street 1:415 E MENOMONEE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6117
Mailing Address - Country:US
Mailing Address - Phone:612-670-7134
Mailing Address - Fax:
Practice Address - Street 1:415 E MENOMONEE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6117
Practice Address - Country:US
Practice Address - Phone:612-670-7134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI720354251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services