1710996566 NPI number — WHITE EARTH BAND OF CHIPPEWA

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 1710996566 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:
1710996566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 418
Provider Second Line Business Mailing Address:
26246 CRANE ROAD
Provider Business Mailing Address City Name:
WHITE EARTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56591-0418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-983-3285
Provider Business Mailing Address Fax Number:
218-983-4299

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:
218-983-4299
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
Authorized Official Title or Position:
EDLERLY NURITION COORDINATOR
Authorized Official Telephone Number:
218-983-3285

Provider Taxonomy Codes

  • Taxonomy code: 332U00000X , with the licence number:  293607100 , 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: 293607100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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