Provider Demographics
NPI:1568404721
Name:MENOMINEE INDIAN TRIBE OF WISCONSIN
Entity Type:Organization
Organization Name:MENOMINEE INDIAN TRIBE OF WISCONSIN
Other - Org Name:MENOMINEE TRIBAL CLINIC
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:2006-06-12
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32955700Medicaid
WI32955700Medicaid
WI000036030Medicare PIN