1013805696 NPI number — WHITE EARTH BAND OF CHIPPEWA INDIANS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013805696 NPI number — WHITE EARTH BAND OF CHIPPEWA INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE EARTH BAND OF CHIPPEWA INDIANS
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:
1013805696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1741 15TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEMIDJI
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56601-8755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-755-7146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33991 VICTORY WAY DR
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:
56569-9537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-751-6553
Provider Business Practice Location Address Fax Number:
218-751-1846
Provider Enumeration Date:
06/24/2025

Additional Information

Authorized Official

Authorized Official Last Name:
SYVERSON
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
218-755-7146

Provider Taxonomy Codes

  • Taxonomy code: 276400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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