Healthcare Provider Details

I. General information

NPI: 1699701375
Provider Name (Legal Business Name): BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53585 NOKOMIS ROAD
ASHLAND WI
54806-4272
US

IV. Provider business mailing address

53585 NOKOMIS ROAD
ASHLAND WI
54806-4272
US

V. Phone/Fax

Practice location:
  • Phone: 715-682-7133
  • Fax: 715-685-7857
Mailing address:
  • Phone: 715-682-7133
  • Fax: 715-685-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateWI

VIII. Authorized Official

Name: MRS. DEBRA ANN TUTOR
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 715-682-7133