Provider Demographics
NPI:1134395684
Name:LAC COURTE OREILLES FAMILY SERVICES PROGRAM
Entity type:Organization
Organization Name:LAC COURTE OREILLES FAMILY SERVICES PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:STUERKE
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW
Authorized Official - Phone:715-634-8934
Mailing Address - Street 1:13394 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-634-8934
Mailing Address - Fax:715-634-4797
Practice Address - Street 1:13394 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-634-8934
Practice Address - Fax:715-634-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43085900Medicaid