Healthcare Provider Details

I. General information

NPI: 1629070180
Provider Name (Legal Business Name): STOCKBRIDGE MUNSEE COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W12802 CTY RD A
BOWLER WI
54416
US

IV. Provider business mailing address

P.O. BOX 70 W12802 CTY RD A
BOWLER WI
54416
US

V. Phone/Fax

Practice location:
  • Phone: 715-793-4144
  • Fax: 715-793-5028
Mailing address:
  • Phone: 715-793-4144
  • Fax: 715-793-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. WALLACE A. MILLER
Title or Position: TRIBAL CHAIRMAN
Credential:
Phone: 715-793-4111