Provider Demographics
NPI:1679781116
Name:LEECH LAKE BAND OF OJIBWE
Entity Type:Organization
Organization Name:LEECH LAKE BAND OF OJIBWE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGGLEYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-8200
Mailing Address - Street 1:115 SIXTH STREET NORTHWEST
Mailing Address - Street 2:SUITE E
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-8308
Mailing Address - Fax:218-335-8307
Practice Address - Street 1:115 SIXTH STREET NORTHWEST
Practice Address - Street 2:SUITE E
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-8308
Practice Address - Fax:218-335-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children