Healthcare Provider Details

I. General information

NPI: 1376455691
Provider Name (Legal Business Name): LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4559 WESSON STREET SUITE 100
DETROIT MI
48210
US

IV. Provider business mailing address

PO BOX 9
WATERSMEET MI
49969-0009
US

V. Phone/Fax

Practice location:
  • Phone: 313-600-0189
  • Fax:
Mailing address:
  • Phone: 313-600-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: SADIE VALLIERE
Title or Position: ADMINISTRATOR
Credential:
Phone: 906-358-4587