Provider Demographics
NPI:1275606808
Name:RED CLIFF BAND OF :AKE SUPERIOR
Entity Type:Organization
Organization Name:RED CLIFF BAND OF :AKE SUPERIOR
Other - Org Name:RED CLIFF COMM HEALTH CENTER PHY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-779-3700
Mailing Address - Street 1:36745 AIKEN RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3157
Mailing Address - Fax:715-779-3752
Practice Address - Street 1:36745 AIKEN RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4579
Practice Address - Country:US
Practice Address - Phone:715-779-3157
Practice Address - Fax:715-779-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108718OtherPK
WI32956200Medicaid