Healthcare Provider Details

I. General information

NPI: 1891659215
Provider Name (Legal Business Name): LAC COURTE OREILLES GOVERNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13856 W CORBINE DR
STONE LAKE WI
54876-4001
US

IV. Provider business mailing address

13856 W CORBINE DR
STONE LAKE WI
54876-4001
US

V. Phone/Fax

Practice location:
  • Phone: 715-558-7939
  • Fax:
Mailing address:
  • Phone: 715-558-7939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MARY WOLF
Title or Position: DIRECTOR
Credential:
Phone: 715-558-7939