Provider Demographics
NPI:1851301378
Name:WHITE EARTH BAND OF CHIPPEWA
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:WHITE EARTH DIABETES PROJECT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIABETES PROJECT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:EP
Authorized Official - Phone:218-983-3285
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
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:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN464M3WHOtherBCBS OF MN & CCS TPA
MN464M3WHOtherBCBS OF MN & CCS TPA