Provider Demographics
NPI:1679116685
Name:MDC MILWAUKEE, LLC
Entity type:Organization
Organization Name:MDC MILWAUKEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOLKA
Authorized Official - Suffix:IV
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-579-3188
Mailing Address - Street 1:PO BOX 1658
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1658
Mailing Address - Country:US
Mailing Address - Phone:920-579-3188
Mailing Address - Fax:
Practice Address - Street 1:4701 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3521
Practice Address - Country:US
Practice Address - Phone:920-579-3188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental