Provider Demographics
NPI:1588115018
Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Entity type:Organization
Organization Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PNCC NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:715-682-7133
Mailing Address - Street 1:53585 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-682-7133
Mailing Address - Fax:715-685-7857
Practice Address - Street 1:53585 NOKOMIS RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:715-685-7857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160502163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty