Provider Demographics
NPI:1366814162
Name:MILWAUKEE INDONESIA MEDICAL CLINIC
Entity type:Organization
Organization Name:MILWAUKEE INDONESIA MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERR
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-397-1654
Mailing Address - Street 1:6300 N 76TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-1208
Mailing Address - Country:US
Mailing Address - Phone:414-446-4660
Mailing Address - Fax:
Practice Address - Street 1:6300 N 76TH ST STE 250
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-1208
Practice Address - Country:US
Practice Address - Phone:414-446-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No122300000XDental ProvidersDentistGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty