Provider Demographics
NPI:1215823406
Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STAMPFL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-771-3561
Mailing Address - Street 1:4006 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4819
Mailing Address - Country:US
Mailing Address - Phone:262-771-3561
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:930 DR MARTIN LUTHER KING DR # 3
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3008
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-764-3636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENOSHA COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100328514Medicaid