Provider Demographics
NPI:1821305129
Name:PRAIRIE ISLAND INDIAN COMMUNITY
Entity Type:Organization
Organization Name:PRAIRIE ISLAND INDIAN COMMUNITY
Other - Org Name:PRAIRIE ISLAND COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL COUNCIL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-385-4105
Mailing Address - Street 1:1158 ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:MN
Mailing Address - Zip Code:55089-9540
Mailing Address - Country:US
Mailing Address - Phone:651-385-4148
Mailing Address - Fax:651-385-4170
Practice Address - Street 1:1158 ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:MN
Practice Address - Zip Code:55089-9540
Practice Address - Country:US
Practice Address - Phone:651-385-4148
Practice Address - Fax:651-385-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center