Provider Demographics
NPI:1275748543
Name:WHITE EARTH HEALTH CENTER
Entity Type:Organization
Organization Name:WHITE EARTH HEALTH CENTER
Other - Org Name:PINE POINT HEALTH STATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REDGRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-6214
Mailing Address - Street 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-573-2162
Mailing Address - Fax:218-573-3888
Practice Address - Street 1:47520 282 STREET
Practice Address - Street 2:
Practice Address - City:PONSFORD
Practice Address - State:MN
Practice Address - Zip Code:56575
Practice Address - Country:US
Practice Address - Phone:218-573-2162
Practice Address - Fax:218-573-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN246753400Medicaid
MN5511210001OtherDMEPOS SUPPLIER NUMBER
MNHSZ052Medicare ID - Type UnspecifiedMEDICARE PART B