Provider Demographics
NPI:1174944110
Name:WHITE EARTH BAND OF CHIPPEWA
Entity type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRWOMAN
Authorized Official - Prefix:
Authorized Official - First Name:ERMA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIZENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-3286
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:26246 CRANE RD
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0327
Mailing Address - Country:US
Mailing Address - Phone:218-983-3286
Mailing Address - Fax:
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE EARTH BAND OF CHIPPEWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment