Provider Demographics
NPI:1669970729
Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity type:Organization
Organization Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE & CONTRACT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHLBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-588-4422
Mailing Address - Street 1:PO BOX 815
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-0815
Mailing Address - Country:US
Mailing Address - Phone:715-588-4422
Mailing Address - Fax:715-588-1889
Practice Address - Street 1:3378 N. SCHILLEMAN RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-0815
Practice Address - Country:US
Practice Address - Phone:715-388-0762
Practice Address - Fax:715-588-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QF0400X
WI3100324500000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility