Provider Demographics
NPI:1366654980
Name:ST. CROIX TRIBAL COUNCIL
Entity Type:Organization
Organization Name:ST. CROIX TRIBAL COUNCIL
Other - Org Name:ST. CROIX TRIBAL OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-8554
Mailing Address - Street 1:4404 STATE ROAD 70
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-9251
Mailing Address - Country:US
Mailing Address - Phone:715-349-8554
Mailing Address - Fax:715-349-2559
Practice Address - Street 1:4404 STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-9251
Practice Address - Country:US
Practice Address - Phone:715-349-8554
Practice Address - Fax:715-349-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2728-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU74072Medicare UPIN