1194975136 NPI number — WHITE EARTH HEALTHCARE CENTER

Table of content: (NPI 1194975136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194975136 NPI number — WHITE EARTH HEALTHCARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE EARTH HEALTHCARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194975136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28920 COUNTY ROAD 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALLAWAY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56521-9642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-375-2115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40520 COUNTY HIGHWAY 34
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGEMA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56569-9612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-983-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HUSBY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
INGRID
Authorized Official Title or Position:
COTA/L
Authorized Official Telephone Number:
218-983-4300

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  201299 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X , with the licence number: 10147 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X , with the licence number: 3661 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)