Provider Demographics
NPI:1285186007
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity Type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:FOUR WINDS LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HHS COMMISSIONER
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 1:11600 STATE AVE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:320-532-4163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS BAND OF OJIBWE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-27
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility