Healthcare Provider Details

I. General information

NPI: 1851301378
Provider Name (Legal Business Name): WHITE EARTH BAND OF CHIPPEWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

26246 CRANE RD
WHITE EARTH MN
56591-9998
US

IV. Provider business mailing address

PO BOX 418
WHITE EARTH MN
56591-0418
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-3285
  • Fax: 218-983-4299
Mailing address:
  • Phone: 218-983-3285
  • Fax: 218-983-4299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. MONTE FOX
Title or Position: DIABETES PROJECT MANAGER
Credential: EP
Phone: 218-983-3285