Provider Demographics
NPI:1164659652
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity Type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:EAST LAKE ALCOHOL & DRUG PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMISSIONER OF HEALTH & HUMAN SERV
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:56359-3001
Mailing Address - Country:US
Mailing Address - Phone:320-532-4163
Mailing Address - Fax:320-532-7495
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:218-768-2431
Practice Address - Fax:218-768-2697
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS BAND OF OJIBWE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-11
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherEIN