Healthcare Provider Details

I. General information

NPI: 1760680300
Provider Name (Legal Business Name): PONEMAH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 1 BOX 497
RED LAKE MN
56671
US

IV. Provider business mailing address

HWY 1 BOX 497
RED LAKE MN
56671
US

V. Phone/Fax

Practice location:
  • Phone: 218-679-3912
  • Fax: 218-679-0181
Mailing address:
  • Phone: 218-679-3912
  • Fax: 218-679-0181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN DUDLEY
Title or Position: MEDICAL STAFF COOR.
Credential:
Phone: 218-679-3912