Healthcare Provider Details

I. General information

NPI: 1366195133
Provider Name (Legal Business Name): WHITE EARTH BAND OF CHIPPEWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 03/01/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 WORKFORCE CENTER ROAD
MAHNOMEN MN
56557
US

IV. Provider business mailing address

PO BOX 70
NAYTAHWAUSH MN
56566-0070
US

V. Phone/Fax

Practice location:
  • Phone: 218-935-5554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA ANN BUTLER
Title or Position: HEALTH DIRECTOR
Credential:
Phone: 218-983-3286