Provider Demographics
NPI:1326053166
Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type:Organization
Organization Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Other - Org Name:FOND DU LAC HUMAN SERVICES DIVISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-879-1227
Mailing Address - Street 1:927 TRETTLE LANE
Mailing Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:218-878-3800
Practice Address - Street 1:927 TRETTLE LANE
Practice Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261Q00000X
MN012003261QR0405X
MN5985000001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN666815100Medicaid
MN666815101Medicaid
MN8F27FOOtherBCBS AODA
MN8F27FOOtherBCBS AODA
MN666815100Medicaid