Provider Demographics
NPI:1306016563
Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:FAMILY RESOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRC EXEC. ADMIN ASST.
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-588-1511
Mailing Address - Street 1:533 PEACE PIPE ROAD
Mailing Address - Street 2:PO BOX 189
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-0189
Mailing Address - Country:US
Mailing Address - Phone:715-588-1511
Mailing Address - Fax:715-588-3903
Practice Address - Street 1:533 PEACE PIPE ROAD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-0189
Practice Address - Country:US
Practice Address - Phone:715-588-1511
Practice Address - Fax:715-588-3903
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-04
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42145400Medicaid
WI43084300Medicaid