1366618506 NPI number — BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDAINS WIS

Table of content: (NPI 1366618506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366618506 NPI number — BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDAINS WIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDAINS WIS
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:
BAD RIVER AODA BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
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:
1366618506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53585 NOKOMIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54806-4272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-682-7133
Provider Business Mailing Address Fax Number:
715-685-7857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53585 NOKOMIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54806-4272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-682-7133
Provider Business Practice Location Address Fax Number:
715-685-7857
Provider Enumeration Date:
05/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TUTOR
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
715-682-7133

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  2728 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42202100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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