Provider Demographics
NPI:1194490763
Name:ANISHINAABE ENDAAD LLC
Entity type:Organization
Organization Name:ANISHINAABE ENDAAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-208-6613
Mailing Address - Street 1:3529 ZENITH AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 2ND ST NW
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557-4316
Practice Address - Country:US
Practice Address - Phone:612-208-6613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health