Healthcare Provider Details

I. General information

NPI: 1861751562
Provider Name (Legal Business Name): BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72772 ELM STREET
ODANAH WI
54861-0055
US

IV. Provider business mailing address

PO BOX 55
ODANAH WI
54861-0055
US

V. Phone/Fax

Practice location:
  • Phone: 715-682-7127
  • Fax: 715-682-7883
Mailing address:
  • Phone: 715-682-7127
  • Fax: 715-682-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ESIE LEOSO
Title or Position: SOCIAL AND FAMILY SERVICES DIRECTOR
Credential:
Phone: 715-682-7127