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
State | License ID | Taxonomies |
---|---|---|
WI | 720354 | 251C00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251C00000X | Agencies | Day Training, Developmentally Disabled Services |