Healthcare Provider Details

I. General information

NPI: 1568404721
Provider Name (Legal Business Name): MENOMINEE INDIAN TRIBE OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3275 WOLF RIVER ROAD
KESHENA WI
54135
US

IV. Provider business mailing address

PO BOX 970
KESHENA WI
54135-0970
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3361
  • Fax: 715-799-3099
Mailing address:
  • Phone: 715-799-3361
  • Fax: 715-799-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY L WAUKAU SR.
Title or Position: HEALTH ADMINISTRATOR
Credential:
Phone: 715-799-3361