Provider Demographics
NPI:1649295502
Name:WHITE EARTH BAND OF CHIPPEWA
Entity type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHN-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, PHN
Authorized Official - Phone:218-983-3285
Mailing Address - Street 1:PO BOX 496
Mailing Address - Street 2:26246 CRANE RD
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0496
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-3724
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:218-983-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330865251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN151255201Medicaid
MN5900118OtherMEDICA
MN151255200,727667200Medicaid
MN8297WHOtherBCBS OF MN
MN151255201Medicaid