1801065495 NPI number — LEECH LAKE BAND OF OJIBWE

Table of content: (NPI 1801065495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801065495 NPI number — LEECH LAKE BAND OF OJIBWE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEECH LAKE BAND OF OJIBWE
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:
AHNJI-BE-MAH-DIZ RECOVERY CENTER
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:
1801065495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 SAILSTAR DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASS LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-335-6880
Provider Business Mailing Address Fax Number:
218-335-7760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16599 69TH AVENUE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASS LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-335-6880
Provider Business Practice Location Address Fax Number:
218-335-7760
Provider Enumeration Date:
02/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
EARL
Authorized Official Middle Name:
Authorized Official Title or Position:
HUMAN SERVICES DIRECTOR
Authorized Official Telephone Number:
218-335-8295

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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