Provider Demographics
NPI:1801065495
Name:LEECH LAKE BAND OF OJIBWE
Entity type:Organization
Organization Name:LEECH LAKE BAND OF OJIBWE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-8295
Mailing Address - Street 1:190 SAILSTAR DR NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-6880
Mailing Address - Fax:218-335-7760
Practice Address - Street 1:16599 69TH AVENUE NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-6880
Practice Address - Fax:218-335-7760
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEECH LAKE BAND OF OJIBWE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility