52D2093179 CLIA NUMBER - PRADER-WILLI HOMES OF OCONOMOWOC HEALTH SERVICES

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Laboratory Demographics

CLIA Number: 52D2093179

Facility Name: PRADER-WILLI HOMES OF OCONOMOWOC HEALTH SERVICES

Facility Address:
1746 EXECUTIVE DR
OCONOMOWOC, WI
ZIP 53066
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Facility Phone Number: 262 569-5515

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1396891875

Taxonomy: 320900000X - Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities.

CLIA Record

Field Name	Field Value
CLIA Number	52D2093179
LAB Type	Assisted Living Facility
Facility Name	PRADER-WILLI HOMES OF OCONOMOWOC HEALTH SERVICES
Street	1746 EXECUTIVE DR
City	OCONOMOWOC
State	WI
ZIP	53066
Phone	262 569-5515
CertificateType	4
CertificateEffectiveDate	3/23/2023
CertificateExpirationDate	3/22/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024