Provider Demographics
NPI:1962698571
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMISSIONER HEALTH & HUMAN SVCS
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-4163
Mailing Address - Street 1:18562 MINOBIMAADIZI LOOP
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359
Mailing Address - Country:US
Mailing Address - Phone:320-532-4163
Mailing Address - Fax:320-532-4354
Practice Address - Street 1:36666 STATE HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:MCGREGOR
Practice Address - State:MN
Practice Address - Zip Code:55760
Practice Address - Country:US
Practice Address - Phone:218-768-3311
Practice Address - Fax:218-768-6124
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS BAND OF OJIBWE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-18
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN085753000Medicaid
MN085753000Medicaid