Provider Demographics
NPI:1174071658
Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:KENOSHA COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCHUGH-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:262-764-3608
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:2310 CENTER ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-3330
Practice Address - Country:US
Practice Address - Phone:262-764-3608
Practice Address - Fax:262-764-3636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FQHC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI521810Medicare PIN
WI000032270Medicare PIN
WI521844Medicare PIN
WI521835Medicare PIN