Provider Demographics
NPI:1629070180
Name:STOCKBRIDGE MUNSEE COMMUNITY
Entity Type:Organization
Organization Name:STOCKBRIDGE MUNSEE COMMUNITY
Other - Org Name:STOCKBRIDGE MUNSEE HEALTH & WELLNESS CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-793-4111
Mailing Address - Street 1:P.O. BOX 70
Mailing Address - Street 2:W12802 CTY RD A
Mailing Address - City:BOWLER
Mailing Address - State:WI
Mailing Address - Zip Code:54416
Mailing Address - Country:US
Mailing Address - Phone:715-793-4144
Mailing Address - Fax:715-793-5028
Practice Address - Street 1:W12802 CTY RD A
Practice Address - Street 2:
Practice Address - City:BOWLER
Practice Address - State:WI
Practice Address - Zip Code:54416
Practice Address - Country:US
Practice Address - Phone:715-793-4144
Practice Address - Fax:715-793-5028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32955900Medicaid
WI41730300Medicaid
WI44008700Medicaid
WI39114544+040OtherBLUE CROSS BLUE SHIELD
WI42125400Medicaid
WI41730300Medicaid
WI0786070001Medicare NSC