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General NPI Number Information
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NPI Number | 1114071578
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Entity Type | Organization
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Legal Business Name | LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 09/11/2023
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Provider Practice Location Address
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Address Line | N5241 US HIGHWAY 45
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City | WATERSMEET
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State | MI
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Zip | 49969-0009
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Country | US
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Telephone | 906-358-4588
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Fax | 906-358-4118
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Provider Business Mailing Address
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Address Line | PO BOX 9
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City | WATERSMEET
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State | MI
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Zip | 49969-0009
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Country | US
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Telephone | 906-358-4588
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Fax | 906-358-4118
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Authorized Official
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Title or Position | LAC VIEUX DESERT TRIBAL CHAIRMAN
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Name | JAMES WILLIAMS JR.
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Credential |
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Telephone | 906-358-4577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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