1518153436 NPI number — MENOMINEE INDIAN TRIBE OF WISCONSIN

Table of content: (NPI 1518153436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518153436 NPI number — MENOMINEE INDIAN TRIBE OF WISCONSIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENOMINEE INDIAN TRIBE OF WISCONSIN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MENOMINEE TRIBAL CLINIC-PRENATAL CARE COORDINATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518153436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KESHENA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54135-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-799-3361
Provider Business Mailing Address Fax Number:
715-799-3099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W3275 WOLF RIVER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KESHENA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-799-3361
Provider Business Practice Location Address Fax Number:
715-799-3099
Provider Enumeration Date:
09/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAUKAU
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
HEALTH ADMINISTRATOR
Authorized Official Telephone Number:
715-799-3361

Provider Taxonomy Codes

  • Taxonomy code: 261QF0050X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 44002800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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