1629070180 NPI number — STOCKBRIDGE MUNSEE COMMUNITY

Table of content: (NPI 1629070180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629070180 NPI number — STOCKBRIDGE MUNSEE COMMUNITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOCKBRIDGE MUNSEE COMMUNITY
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:
STOCKBRIDGE MUNSEE HEALTH & WELLNESS CTR
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:
1629070180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 70
Provider Second Line Business Mailing Address:
W12802 CTY RD A
Provider Business Mailing Address City Name:
BOWLER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-793-4144
Provider Business Mailing Address Fax Number:
715-793-5028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W12802 CTY RD A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWLER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-793-4144
Provider Business Practice Location Address Fax Number:
715-793-5028
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
TRIBAL CHAIRMAN
Authorized Official Telephone Number:
715-793-4111

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32955900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41730300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44008700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39114544+040 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 42125400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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