Provider Demographics
NPI:1467862334
Name:WHITE EARTH BAND OF CHIPPWA INDIANS
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPWA INDIANS
Other - Org Name:WHITE EARTH MEN'S SUBSTANCE ABUSE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUTE CARE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BELLANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:218-983-3285
Mailing Address - Street 1:2388 STATE HIGHWAY 200
Mailing Address - Street 2:
Mailing Address - City:MAHNOMEN
Mailing Address - State:MN
Mailing Address - Zip Code:56557-9370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2388 STATE HIGHWAY 200
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557-9370
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE EARTH BAND OF CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0013324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility