MEDICARE: LEECH LAKE TRIBAL COUNCIL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	83080LE	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1447264866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEECH LAKE TRIBAL COUNCIL

Provider Business Mailing Address
First Line	:	3920 13TH AVE E
Second Line	:	SUITE 6
City	:	HIBBING
State	:	MN
Zip	:	55746-3675
Country	:	US
Telephone Number	:	218-263-7540
Fax Number	:	866-732-0699

Provider Business Practice Location Address
First Line	:	115 6TH ST. NW
Second Line	:	SUITE E
City	:	CASS LAKE
State	:	MN
Zip	:	56633
Country	:	US
Telephone Number	:	218-335-6363
Fax Number	:

Authorized Official
Title or Position	:	TRIBAL COUNCIL MEMBERS
Name	:	LEECH LAKE TRIBAL COUNCIL
Credential	:
Telephone Number	:	218-335-8200

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	04/18/2008

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