Provider Demographics
NPI:1811104995
Name:PROFESSIONAL RECOVERY NETWORK
Entity type:Organization
Organization Name:PROFESSIONAL RECOVERY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-549-6600
Mailing Address - Street 1:2422 NORTH GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:262-549-6698
Practice Address - Street 1:2422 NORTH GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:262-549-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1747324500000X
WI1748324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility