Provider Demographics
NPI:1760536007
Name:LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:LAC VIEUX DESERT HEALTH CENTER AND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SADIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-358-4587
Mailing Address - Street 1:N5241 US HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-5115
Mailing Address - Country:US
Mailing Address - Phone:906-358-4905
Mailing Address - Fax:906-358-4929
Practice Address - Street 1:N5241 US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-5115
Practice Address - Country:US
Practice Address - Phone:906-358-4905
Practice Address - Fax:906-358-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X
MI5301006253333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33205200Medicaid
MI2354455Medicaid