1811245137 NPI number — CIRCLE BACK CENTER

Table of content: (NPI 1811245137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811245137 NPI number — CIRCLE BACK CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CIRCLE BACK 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:
WHITE EARTH TRIBAL COUNCIL
Provider Other Organization Name Type Code:
5
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:
1811245137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35708 CO. HWY. 21
Provider Second Line Business Mailing Address:
P.O. BOX 418
Provider Business Mailing Address City Name:
WHITE EARTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-983-3285
Provider Business Mailing Address Fax Number:
218-983-3027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35708 CO. HWY. 21
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:
56569-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-983-3285
Provider Business Practice Location Address Fax Number:
218-983-3027
Provider Enumeration Date:
08/16/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TONIHKA
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
218-983-3285

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0008 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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