Provider Demographics
NPI:1497744015
Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:RED CLIFF COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SERVICES ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-779-3707
Mailing Address - Street 1:36745 AIKEN RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3362
Practice Address - Street 1:36745 AIKEN RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4579
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3362
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED CLIFF BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-17
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 183500000X, 261QD0000X, 261QP2300X
WI1041C0700X, 163W00000X, 332B00000X, 341600000X
WI32956200261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS3144OtherRR RETIREMENT PALMETTO
WI32956200Medicaid
WI44004200Medicaid
10170-001OtherGROUP PLAN # DENTAL
WI44004200Medicaid
MN587418100Medicaid
MN587418100Medicaid