Healthcare Provider Details

I. General information

NPI: 1629256763
Provider Name (Legal Business Name): FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W 4TH ST
DULUTH MN
55806-2719
US

IV. Provider business mailing address

FOND DU LAC HUMAN SERV DIVISION 927 TRETTEL LANE
CLOQUET MN
55720
US

V. Phone/Fax

Practice location:
  • Phone: 218-279-4142
  • Fax: 218-279-4077
Mailing address:
  • Phone: 218-829-1227
  • Fax: 218-878-2188

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 Number260913
License Number StateMN

VIII. Authorized Official

Name: MARILYN GROVER
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 218-879-1227