Healthcare Provider Details

I. General information

NPI: 1023729597
Provider Name (Legal Business Name): ST. CROIX CHIPPEWA INDIANS OF WI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 175TH AVE
TURTLE LAKE WI
54889-9142
US

IV. Provider business mailing address

361 175TH AVE
TURTLE LAKE WI
54889-9142
US

V. Phone/Fax

Practice location:
  • Phone: 715-619-0015
  • Fax:
Mailing address:
  • Phone: 715-619-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TODD MEINBURG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 715-619-0015