NPIMap

Organization Active NPI

Menominee Indian Tribe of Wisconsin

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Keshena, WI
National Provider Identifier
1124291802
Registry record updated Apr 2, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
License
1588 Issued in WI
Legal business name
MENOMINEE INDIAN TRIBE OF WISCONSIN
Practice address
W3275 Wolf River Road
Keshena, WI 54135
Phone
(715) 799-3361
Fax
(715) 799-3099
NPI assigned
Apr 2, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 2, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jerry L Waukau
Title
Health Administrator
Phone
(715) 799-3361

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X 1588 WI Primary

Addresses

Primary practice location

W3275 Wolf River Road
Keshena, WI 54135

Mailing address

PO Box 970
Keshena, WI 54135-0970
Phone (715) 799-3361

Other identifiers 1

IdentifierTypeStateIssuer
42173700MedicaidWI

Other names 1

  • MTC Mental Health Services Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Menominee Tribl Res SQ7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1207094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1207094400000",
    "number": "1124291802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 970",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "541350970",
            "telephone_number": "715-799-3361",
            "fax_number": "715-799-3099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W3275 WOLF RIVER ROAD",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "54135",
            "telephone_number": "715-799-3361",
            "fax_number": "715-799-3099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENOMINEE INDIAN TRIBE OF WISCONSIN",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-02",
        "last_updated": "2008-04-02",
        "status": "A",
        "authorized_official_last_name": "WAUKAU",
        "authorized_official_first_name": "JERRY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "HEALTH ADMINISTRATOR",
        "authorized_official_telephone_number": "715-799-3361"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "WI",
            "license": "1588",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "42173700",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MTC Mental Health Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Keshena, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.