MEDICARE: BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.

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	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780702829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.

Provider Business Mailing Address
First Line	:	53585 NOKOMIS ROAD
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-4272
Country	:	US
Telephone Number	:	715-682-8518
Fax Number	:	715-682-7753

Provider Business Practice Location Address
First Line	:	53585 NOKOMIS ROAD
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-4272
Country	:	US
Telephone Number	:	715-682-7133
Fax Number	:	715-685-8810

Authorized Official
Title or Position	:	BILLING/PRC MANAGER
Name	:	JUNE LOUISE WILLIAMS
Credential	:
Telephone Number	:	715-682-7133

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	06/03/2024

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