1174672844 NPI number — RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS

Table of content: PHILIP EDWARD RYAN MHC (NPI 1013600097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174672844 NPI number — RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED CLIFF BAND OF LAKE SUPERIOR 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:
6
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:
1174672844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36745 AIKEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54814-4579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-779-3707
Provider Business Mailing Address Fax Number:
715-779-3362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37435 STH 13
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-779-3733
Provider Business Practice Location Address Fax Number:
715-779-3704
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH SERVICES ADMINSTRATOR
Authorized Official Telephone Number:
715-779-3707

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , 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: 41337000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com