1275748543 NPI number — WHITE EARTH HEALTH CENTER

Table of content: (NPI 1275748543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275748543 NPI number — WHITE EARTH HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE EARTH HEALTH 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:
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:
1275748543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40520 COUNTY HIGHWAY 34
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGEMA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56569-9612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-573-2162
Provider Business Mailing Address Fax Number:
218-573-3888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47520 282 STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONSFORD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-573-2162
Provider Business Practice Location Address Fax Number:
218-573-3888
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REDGRAVE
Authorized Official First Name:
BRYCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official Telephone Number:
218-983-6214

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 246753400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5511210001 . This is a "DMEPOS SUPPLIER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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