1760536007 NPI number — LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS

Table of content: (NPI 1760536007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760536007 NPI number — LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAC VIEUX DESERT 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:
1760536007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N5241 US HIGHWAY 45
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERSMEET
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49969-5115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-358-4905
Provider Business Mailing Address Fax Number:
906-358-4929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N5241 US HIGHWAY 45
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERSMEET
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49969-5115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-358-4905
Provider Business Practice Location Address Fax Number:
906-358-4929
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VALLIERE
Authorized Official First Name:
SADIE
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
906-358-4587

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 333600000X , with the licence number: 5301006253 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 33205200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2354455 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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