Provider Demographics
NPI:1427263706
Name:WHITE EARTH HEALTH CENTER
Entity type:Organization
Organization Name:WHITE EARTH HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOEBRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-6214
Mailing Address - Street 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:218-983-6217
Practice Address - Street 1:NAYTAHWAUSH HEALTH STATION 238 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:NAYTAHWAUSH
Practice Address - State:MN
Practice Address - Zip Code:56566
Practice Address - Country:US
Practice Address - Phone:218-935-2238
Practice Address - Fax:218-935-5085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE EARTH HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-11
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5511210002OtherDMEPOS SUPPLIER NUMBER
MN246753400Medicaid
MN5511210002OtherDMEPOS SUPPLIER NUMBER