Provider Demographics
NPI:1457317273
Name:KAUKAUNA CLINIC, S.C.
Entity Type:Organization
Organization Name:KAUKAUNA CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DANZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-766-4656
Mailing Address - Street 1:305 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2865
Mailing Address - Country:US
Mailing Address - Phone:920-766-4656
Mailing Address - Fax:920-766-4659
Practice Address - Street 1:305 E 12TH ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2865
Practice Address - Country:US
Practice Address - Phone:920-766-4656
Practice Address - Fax:920-766-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32792500Medicaid
WI45044Medicare ID - Type Unspecified