Provider Demographics
NPI:1033129556
Name:WHITE EARTH BAND OF CHIPPEWA
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:WHITE EARTH RESERVATION AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-936-5586
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0328
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-4299
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:218-983-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03543416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8183263OtherMEDICA
MN56M66WHOtherBLUE CROSS BLUE SHIELD
MN8183263OtherMEDICA
AB0004Medicare PIN