Provider Demographics
NPI:1164618088
Name:MENOMINEE INDIAN TRIBE OF WISCONSIN
Entity Type:Organization
Organization Name:MENOMINEE INDIAN TRIBE OF WISCONSIN
Other - Org Name:MENOMINEE TRIBAL CLINIC-WOMEN'S PERSONAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAUKAU
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:715-799-3361
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0970
Mailing Address - Country:US
Mailing Address - Phone:715-799-3361
Mailing Address - Fax:715-799-3099
Practice Address - Street 1:W3275 WOLF RIVER ROAD
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135
Practice Address - Country:US
Practice Address - Phone:715-799-3361
Practice Address - Fax:715-799-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI93107-030261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42010500Medicaid
WI000036030Medicare PIN