Provider Demographics
NPI:1639368863
Name:LEECH LAKE RESERVATION
Entity Type:Organization
Organization Name:LEECH LAKE RESERVATION
Other - Org Name:TRIBAL HEALTH/NON-IHS
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-4500
Mailing Address - Street 1:115 6TH ST NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3428
Mailing Address - Country:US
Mailing Address - Phone:218-335-4500
Mailing Address - Fax:218-335-4513
Practice Address - Street 1:115 6TH ST NE
Practice Address - Street 2:SUITE E
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3428
Practice Address - Country:US
Practice Address - Phone:218-335-4500
Practice Address - Fax:218-335-4513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEECH LAKE BAND OF OJIBWE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)