Provider Demographics
NPI:1447353883
Name:WHITE EARTH BAND OF CHIPPEWA
Entity type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHEMICAL DEPENDENCY COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:219-983-3285
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0435
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-3729
Practice Address - Street 1:35708 CTY HWY 21
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:218-983-3729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3A25WHOtherBCBS OF MN