Provider Demographics
NPI:1972139814
Name:RED LAKE BAND OF CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:RED LAKE BAND OF CHIPPEWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GEHLERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-1461
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0587
Mailing Address - Country:US
Mailing Address - Phone:218-679-1461
Mailing Address - Fax:
Practice Address - Street 1:34966 605TH AVE
Practice Address - Street 2:
Practice Address - City:WARROAD
Practice Address - State:MN
Practice Address - Zip Code:56763-9022
Practice Address - Country:US
Practice Address - Phone:800-815-8293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED LAKE BAND OF CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy