Healthcare Provider Details

I. General information

NPI: 1558463877
Provider Name (Legal Business Name): WHITE EARTH BAND OF CHIPPEWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 STATE HWY 200
MAHNOMEN MN
56557
US

IV. Provider business mailing address

PO BOX 359
MAHNOMEN MN
56557-0359
US

V. Phone/Fax

Practice location:
  • Phone: 218-936-5653
  • Fax: 218-936-5655
Mailing address:
  • Phone: 218-936-5653
  • Fax: 218-936-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateMN

VIII. Authorized Official

Name: PATRICIA MORAN
Title or Position: CHEMICAL DEPENDENCY COORDINATOR
Credential: LADC
Phone: 218-983-3285