Provider Demographics
NPI:1144686106
Name:NORTHWEST INDIAN COMMUNITY DEVELOPMENT CENTER
Entity type:Organization
Organization Name:NORTHWEST INDIAN COMMUNITY DEVELOPMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS AND FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CONN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-759-2022
Mailing Address - Street 1:1819 BEMIDJI AVE N STE 1
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3874
Mailing Address - Country:US
Mailing Address - Phone:218-759-2022
Mailing Address - Fax:218-759-0090
Practice Address - Street 1:1819 BEMIDJI AVE N STE 1
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-759-2022
Practice Address - Fax:218-759-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN172V00000XMedicaid
MN3747P1801XMedicaid
MN163WH0200XMedicaid
MN374U00000XMedicaid