Provider Demographics
NPI:1215095641
Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA
Entity type:Organization
Organization Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DERAGON-NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-779-3707
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-0529
Mailing Address - Country:US
Mailing Address - Phone:715-779-4707
Mailing Address - Fax:715-779-3777
Practice Address - Street 1:88385 PIKE RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4818
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty