Provider Demographics
NPI:1699701375
Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS
Entity type:Organization
Organization Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TUTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-7133
Mailing Address - Street 1:53585 NOKOMIS ROAD
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 ROAD
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?:Yes
Parent Organization LBN:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122300000X, 251K00000X, 261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Single Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WITRZ020OtherTRAILBLAZER/MEDICARE
WI32957600Medicaid
WI32957600Medicaid
WI521813Medicare PIN