Provider Demographics
NPI:1134235047
Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity type:Organization
Organization Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-588-3371
Mailing Address - Street 1:129 OLD ABE RD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9386
Mailing Address - Country:US
Mailing Address - Phone:715-588-3371
Mailing Address - Fax:715-588-2031
Practice Address - Street 1:129 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9386
Practice Address - Country:US
Practice Address - Phone:715-588-3371
Practice Address - Fax:715-588-2031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-22
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No251B00000XAgenciesCase Management
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32956800Medicaid
WI41854400Medicaid
WI44004700Medicaid
WI41854400Medicaid