=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467862334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE EARTH BAND OF CHIPPWA INDIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2014
-----------------------------------------------------
Last Update Date | 05/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2388 STATE HIGHWAY 200
-----------------------------------------------------
City | MAHNOMEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56557-9370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-983-3285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2388 STATE HIGHWAY 200
-----------------------------------------------------
City | MAHNOMEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56557-9370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUTE CARE MANAGER
-----------------------------------------------------
Name | ANGELA MARIE BELLANGER
-----------------------------------------------------
Credential | MSW, LICSW
-----------------------------------------------------
Telephone | 218-983-3285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 0013
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------