Healthcare Provider Details

I. General information

NPI: 1780702829
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: 03/27/2007
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
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: 715-685-8810
Mailing address:
  • Phone: 715-682-8518
  • Fax: 715-682-7753

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 Number
License Number State

VIII. Authorized Official

Name: JUNE LOUISE WILLIAMS
Title or Position: BILLING/PRC MANAGER
Credential:
Phone: 715-682-7133