=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780702829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53585 NOKOMIS ROAD
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806-4272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-682-7133
-----------------------------------------------------
Fax | 715-685-8810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53585 NOKOMIS ROAD
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806-4272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-682-8518
-----------------------------------------------------
Fax | 715-682-7753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING/PRC MANAGER
-----------------------------------------------------
Name | JUNE LOUISE WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-682-7133
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------