Provider Demographics
NPI:1396848560
Name:WHITE EARTH BAND OF CHIPPEWA
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:WHITE EARTH THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-936-5586
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0418
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:
Practice Address - Street 1:25519 STATE HIGHWAY 224
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9506
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN277P0WHOtherBCBS OF MN
MN277P0WHOtherBCBS OF MN
C04653Medicare PIN