Provider Demographics
NPI:1710996566
Name:WHITE EARTH BAND OF CHIPPEWA
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:WHITE EARTH ELDERLY NUTRITION
Other - Org Type:Other Name
Authorized Official - Title/Position:EDLERLY NURITION COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-3285
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:26246 CRANE ROAD
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0418
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-4299
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:218-983-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN293607100332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN293607100Medicaid