Provider Demographics
NPI:1932301306
Name:THE HUMAN SERVICE CENTER KOINONIA RESIDENTIAL TREATMENT CENTER
Entity Type:Organization
Organization Name:THE HUMAN SERVICE CENTER KOINONIA RESIDENTIAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AODA ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:NORBERT
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL SUBSTANCE A
Authorized Official - Phone:715-362-5745
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:715-362-5745
Mailing Address - Fax:715-362-2819
Practice Address - Street 1:1991 WINNEBAGO STREET
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-362-5745
Practice Address - Fax:715-362-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility