Healthcare Provider Details

I. General information

NPI: 1447271408
Provider Name (Legal Business Name): LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 OLD ABE RD
LAC DU FLAMBEAU WI
54538
US

IV. Provider business mailing address

129 OLD ABE RD
LAC DU FLAMBEAU WI
54538
US

V. Phone/Fax

Practice location:
  • Phone: 715-588-3371
  • Fax: 715-588-2039
Mailing address:
  • Phone: 715-588-3371
  • Fax: 715-588-2039

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 Number8933-042
License Number StateWI

VIII. Authorized Official

Name: RANDY SAMUELSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 715-588-3371