Provider Demographics
NPI:1003052192
Name:WHITE EARTH BAND OF CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-3286
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-3729
Practice Address - Street 1:36510 COUNTY RD 21
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:218-983-3729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder