1649295502 NPI number — WHITE EARTH BAND OF CHIPPEWA

Table of content: (NPI 1649295502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649295502 NPI number — WHITE EARTH BAND OF CHIPPEWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE EARTH BAND OF CHIPPEWA
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:
1649295502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 496
Provider Second Line Business Mailing Address:
26246 CRANE RD
Provider Business Mailing Address City Name:
WHITE EARTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56591-0496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-983-3285
Provider Business Mailing Address Fax Number:
218-983-3724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26246 CRANE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE EARTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56591-9998
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:
218-983-3742
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHN-MANAGER
Authorized Official Telephone Number:
218-983-3285

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  330865 , 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)

  • Identifier: 151255201 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5900118 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 151255200,727667200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8297WH . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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