Organization
MY INNOVATIVE SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARSHA RENEE BURKLUND CPA (CONTROLLER)
(920) 431-0962
Entity
Organization
Contact information
Practice address
445 S MADISON ST, GREEN BAY, WI 54301-4126
(920) 431-0962
(920) 884-1967
Mailing address
445 S MADISON ST, GREEN BAY, WI 54301-4126
(920) 431-0962
(920) 884-1967
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
320900000X
WI
Other
Enumeration date
09/14/2011
Last updated
09/14/2011
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