Provider Demographics
NPI:1427347426
Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity type:Organization
Organization Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELORS DEGREE
Authorized Official - Phone:715-588-4466
Mailing Address - Street 1:128 OLD ABE ROAD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9682
Mailing Address - Country:US
Mailing Address - Phone:715-588-4466
Mailing Address - Fax:715-588-2269
Practice Address - Street 1:128 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9682
Practice Address - Country:US
Practice Address - Phone:715-588-4466
Practice Address - Fax:715-588-2269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-31
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)