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General NPI Number Information
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NPI Number | 1427347426
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Entity Type | Organization
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Legal Business Name | LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
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Dates
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Enumeration Date | 03/31/2011
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Last Update Date | 01/28/2014
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Provider Practice Location Address
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Address Line | 128 OLD ABE RD
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City | LAC DU FLAMBEAU
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State | WI
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Zip | 54538-9682
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Country | US
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Telephone | 715-588-4466
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Fax | 715-588-2269
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Provider Business Mailing Address
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Address Line | 128 OLD ABE ROAD
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City | LAC DU FLAMBEAU
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State | WI
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Zip | 54538-9682
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Country | US
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Telephone | 715-588-4466
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Fax | 715-588-2269
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Authorized Official
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Title or Position | COMPLIANCE OFFICER
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Name | JEANNE M WOLFE
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Credential | BACHELORS DEGREE
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Telephone | 715-588-4466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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