Provider Demographics
NPI:1124225503
Name:LIFE SKILLS SUPPORT CENTER OF EAU CLAIRE, LTD.
Entity type:Organization
Organization Name:LIFE SKILLS SUPPORT CENTER OF EAU CLAIRE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NINO
Authorized Official - Middle Name:A
Authorized Official - Last Name:VIDIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-730-2947
Mailing Address - Street 1:4907 KEYSTONE XING
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5144
Mailing Address - Country:US
Mailing Address - Phone:715-514-0340
Mailing Address - Fax:
Practice Address - Street 1:4907 KEYSTONE XING
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-5144
Practice Address - Country:US
Practice Address - Phone:505-730-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI50281-020OtherSTATE LICENSE