| NPI | 1992195192 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RUSSELL WILLIAM KINKADE President 262-989-5228 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X (Licence: WI 1296) |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| Enumeration Date | 2015-01-27 |
| Last Update Date | 2023-06-02 |