Healthcare Provider Details

I. General information

NPI: 1760536007
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: 01/23/2007
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N5241 US HIGHWAY 45
WATERSMEET MI
49969-5115
US

IV. Provider business mailing address

N5241 US HIGHWAY 45
WATERSMEET MI
49969-5115
US

V. Phone/Fax

Practice location:
  • Phone: 906-358-4905
  • Fax: 906-358-4929
Mailing address:
  • Phone: 906-358-4905
  • Fax: 906-358-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301006253
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

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