Provider Demographics
NPI:1780702829
Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.
Entity type:Organization
Organization Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/PRC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-7133
Mailing Address - Street 1:53585 NOKOMIS ROAD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-682-8518
Mailing Address - Fax:715-682-7753
Practice Address - Street 1:53585 NOKOMIS ROAD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:715-685-8810
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS WIS.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X
WI183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32787800Medicaid