| Organization Name: | MENOMINEE INDIAN TRIBE OF WISCONSIN |
| NPI Number: | 1124291802 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JERRY L WAUKAU (HEALTH ADMINISTRATOR) |
| Mailing Address: | W3275 Wolf River Road Keshena |
| State: | WI US |
| Postal Code: | 54135 |
| Phone Number: | 7157993361 |
| Fax Number: | 7157993099 |
| NPI Enumeration Date: | 04/02/2008 |
| NPI Last Update Date: | 04/02/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM0801X |
| License Number: | 1588 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Mental Health (Including Community Mental Health Center) |
| Taxonomy Definition: | |