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General NPI Number Information
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NPI Number | 1013805696
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Entity Type | Organization
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Legal Business Name | WHITE EARTH BAND OF CHIPPEWA INDIANS
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Dates
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Enumeration Date | 06/24/2025
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 33991 VICTORY WAY DR
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City | OGEMA
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State | MN
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Zip | 56569-9537
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Country | US
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Telephone | 218-751-6553
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Fax | 218-751-1846
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Provider Business Mailing Address
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Address Line | 1741 15TH ST NW
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City | BEMIDJI
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State | MN
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Zip | 56601-8755
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Country | US
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Telephone | 218-755-7146
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. JEREMY SYVERSON
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Credential | MBA
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Telephone | 218-755-7146
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State |
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