Provider Demographics
NPI:1477744472
Name:KENOSHA COUNTY DIV OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:KENOSHA COUNTY DIV OF PUBLIC HEALTH
Other - Org Name:PUBLIC HEALTH LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-605-6700
Mailing Address - Street 1:8600 SHERIDAN RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6506
Mailing Address - Country:US
Mailing Address - Phone:262-605-6700
Mailing Address - Fax:262-605-6715
Practice Address - Street 1:8600 SHERIDAN RD
Practice Address - Street 2:SUITE 600
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6506
Practice Address - Country:US
Practice Address - Phone:262-605-6700
Practice Address - Fax:262-605-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32924500Medicaid