Provider Demographics
NPI:1174672844
Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:RED CLIFF AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SERVICES ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-779-3707
Mailing Address - Street 1:36745 AIKEN RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3362
Practice Address - Street 1:37435 STH 13
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814
Practice Address - Country:US
Practice Address - Phone:715-779-3733
Practice Address - Fax:715-779-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41337000Medicaid
000085371Medicare ID - Type Unspecified