Provider Demographics
NPI:1215341094
Name:LEECH LAKE BAND OF OJIBWE
Entity type:Organization
Organization Name:LEECH LAKE BAND OF OJIBWE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-8295
Mailing Address - Street 1:190 SAILSTAR DR NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-8382
Mailing Address - Fax:218-335-3580
Practice Address - Street 1:321 2ND ST
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-8382
Practice Address - Fax:218-335-3580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)