1447264866 NPI number — LEECH LAKE TRIBAL COUNCIL

Table of content: (NPI 1447264866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447264866 NPI number — LEECH LAKE TRIBAL COUNCIL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEECH LAKE TRIBAL COUNCIL
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:
1447264866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3920 13TH AVE E
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
HIBBING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55746-3675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-263-7540
Provider Business Mailing Address Fax Number:
866-732-0699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 6TH ST. NW
Provider Second Line Business Practice Location Address:
SUITE E
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:
218-335-6363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRIBAL COUNCIL
Authorized Official First Name:
LEECH LAKE
Authorized Official Middle Name:
Authorized Official Title or Position:
TRIBAL COUNCIL MEMBERS
Authorized Official Telephone Number:
218-335-8200

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 83080LE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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