=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487875787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. CROIX CHIPPEWA INDIANS OF WI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4404 STATE RD 70
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-349-8554
-----------------------------------------------------
Fax | 715-349-8529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4404 STATE RD 70
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-349-8554
-----------------------------------------------------
Fax | 715-349-8529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH DIRECTOR
-----------------------------------------------------
Name | AMBER HEINZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-349-8554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332800000X
-----------------------------------------------------
Taxonomy Name | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------