Provider Demographics
NPI:1942595657
Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Other - Org Name:KENOSHA COMMUNITY CENTER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-764-3608
Mailing Address - Street 1:625 57TH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4146
Mailing Address - Country:US
Mailing Address - Phone:262-656-0044
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:1330 52ND ST
Practice Address - Street 2:SUITE 205
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3236
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-764-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)