Provider Demographics
NPI:1205007796
Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA
Entity Type:Organization
Organization Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA
Other - Org Name:RED CLIFF COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DERAGON-NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-779-3707
Mailing Address - Street 1:88385 PIKE RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4818
Mailing Address - Country:US
Mailing Address - Phone:715-779-3700
Mailing Address - Fax:715-779-3704
Practice Address - Street 1:88455 PIKE ROAD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI772-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42200000OtherMEDICAID-MENTAL HEALTH