Provider Demographics
NPI:1922263656
Name:HO CHUNK NATION
Entity Type:Organization
Organization Name:HO CHUNK NATION
Other - Org Name:HO-CHUNK COMMUNITY HEALTH CARE NURSING PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER NETWORK MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-284-9851
Mailing Address - Street 1:N6520 LUMBERJACK GUY RD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5405
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:715-284-5051
Practice Address - Street 1:N6520 LUMBERJACK GUY RD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5405
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:715-284-5051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HO CHUNK NATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-22
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D2018007OtherCLIA
WI44015100Medicaid