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General NPI Number Information
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NPI Number | 1669970729
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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 | 01/24/2018
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Last Update Date | 09/13/2018
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Provider Practice Location Address
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Address Line | 3378 N. SCHILLEMAN RD
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City | LAC DU FLAMBEAU
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State | WI
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Zip | 54538-0815
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Country | US
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Telephone | 715-388-0762
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Fax | 715-588-1889
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Provider Business Mailing Address
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Address Line | PO BOX 815
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City | LAC DU FLAMBEAU
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State | WI
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Zip | 54538-0815
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Country | US
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Telephone | 715-588-4422
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Fax | 715-588-1889
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Authorized Official
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Title or Position | COMPLIANCE & CONTRACT COORDINATOR
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Name | PAMELA AHLBORN
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Credential |
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Telephone | 715-588-4422
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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 | WI
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 3100
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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