Provider Demographics
NPI:1861773863
Name:CRC WISCONSIN RD LLC
Entity type:Organization
Organization Name:CRC WISCONSIN RD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:615 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-6959
Mailing Address - Country:US
Mailing Address - Phone:715-386-6125
Mailing Address - Fax:715-381-0158
Practice Address - Street 1:615 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-6959
Practice Address - Country:US
Practice Address - Phone:715-386-6125
Practice Address - Fax:715-381-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1118261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder