Provider Demographics
NPI:1902085624
Name:VISTA CARE WISCONSIN INC.
Entity Type:Organization
Organization Name:VISTA CARE WISCONSIN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-457-0826
Mailing Address - Street 1:708 ERIE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4060
Mailing Address - Country:US
Mailing Address - Phone:920-457-0826
Mailing Address - Fax:920-457-2207
Practice Address - Street 1:708 ERIE AVE STE 201
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4060
Practice Address - Country:US
Practice Address - Phone:920-457-0826
Practice Address - Fax:920-457-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 261QM0801X, 261QM0801X
WI11183320600000X, 320600000X
WI9340320900000X, 320900000X
WI8575320600000X
WI490105320600000X
WI11919320600000X
WI11945320600000X
WI13034320600000X
WI13033320600000X
WI10467320900000X
WI11410320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities