Provider Demographics
NPI:1245628817
Name:FOREVER FREE SUBSTANCE ABUSE AND MENTAL HEATH TREAMENT CENTER
Entity type:Organization
Organization Name:FOREVER FREE SUBSTANCE ABUSE AND MENTAL HEATH TREAMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-617-1801
Mailing Address - Street 1:724 S LAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1224
Mailing Address - Country:US
Mailing Address - Phone:414-383-8533
Mailing Address - Fax:
Practice Address - Street 1:724 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1224
Practice Address - Country:US
Practice Address - Phone:414-383-8533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAY OF RIGHTEOUSNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3059261QR0405X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder