Healthcare Provider Details

I. General information

NPI: 1700064714
Provider Name (Legal Business Name): FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3073
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 612-871-1989
  • Fax: 612-222-3463
Mailing address:
  • Phone: 218-879-1227
  • Fax: 218-878-3755

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 Number263031
License Number StateMN

VIII. Authorized Official

Name: MR. MARILYN GROVER
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 218-878-2101