Provider Demographics
NPI:1710222989
Name:BAD RIVER BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:BAD RIVER BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:BAD RIVER HEALTH AND WELLNESS OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TUTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-7133
Mailing Address - Street 1:53585 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-682-7133
Mailing Address - Fax:
Practice Address - Street 1:53585 NOKOMIS RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAD RIVER HEALTH AND WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)