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General NPI Number Information
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NPI Number | 1295029817
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Entity Type | Organization
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Legal Business Name | LEECH LAKE BAND OF OJIBWE
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Dates
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Enumeration Date | 05/31/2011
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Last Update Date | 05/31/2011
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Provider Practice Location Address
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Address Line | 15353 SILVER EAGLE DR NW
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City | BENA
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State | MN
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Zip | 56626-3675
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Country | US
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Telephone | 218-665-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 15353 SILVER EAGLE DR NW
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City | BENA
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State | MN
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Zip | 56626-3675
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MIDDLE SCHOOL PRINCIPAL
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Name | JANEY BLANCHARD
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Credential |
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Telephone | 218-665-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 19439
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License Number State | MN
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