Provider Demographics
NPI:1114071578
Name:LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:LVD HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LAC VIEUX DESERT TRIBAL CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:906-358-4577
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-0009
Mailing Address - Country:US
Mailing Address - Phone:906-358-4588
Mailing Address - Fax:906-358-4118
Practice Address - Street 1:N5241 US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-0009
Practice Address - Country:US
Practice Address - Phone:906-358-4588
Practice Address - Fax:906-358-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB74513OtherBLUE CROSS BLUE SHIELD
MI1114071578Medicaid