Provider Demographics
NPI:1861615874
Name:WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY
Entity type:Organization
Organization Name:WISCONSIN COMMUNITY SERVICES, INC. DRUG EVALUATION LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PATZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-290-0418
Mailing Address - Street 1:3732 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3153
Mailing Address - Country:US
Mailing Address - Phone:414-290-0400
Mailing Address - Fax:414-271-4605
Practice Address - Street 1:949 N 9TH ST
Practice Address - Street 2:ROOM 131E
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1422
Practice Address - Country:US
Practice Address - Phone:414-223-1329
Practice Address - Fax:414-223-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2133-800291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32920400Medicaid