Provider Demographics
NPI:1386977965
Name:OCONOMOWOC DEVELOPMENT TRAINING CENTER LL
Entity type:Organization
Organization Name:OCONOMOWOC DEVELOPMENT TRAINING CENTER LL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:M.
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:FRISK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:262-569-5515
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118
Mailing Address - Country:US
Mailing Address - Phone:262-569-5515
Mailing Address - Fax:262-569-9962
Practice Address - Street 1:307 WILSON AVE.
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118
Practice Address - Country:US
Practice Address - Phone:262-569-5515
Practice Address - Fax:262-569-9962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OCONOMOWOC DEVELOPMENT TRAINING CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities