Provider Demographics
NPI:1720133242
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity Type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:MILLE LACS BAND OF OJIBWE PUBLIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-4163
Mailing Address - Street 1:18562 MINOBIMAADIZI LOOP
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-3001
Mailing Address - Country:US
Mailing Address - Phone:320-532-4163
Mailing Address - Fax:320-532-7495
Practice Address - Street 1:18562 MINOBIMAADIZI LOOP
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-3001
Practice Address - Country:US
Practice Address - Phone:320-532-7459
Practice Address - Fax:320-532-7524
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS BAND OF OJIBWE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare