Provider Demographics
NPI:1861751562
Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Entity type:Organization
Organization Name:BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOCIAL AND FAMILY SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ESIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-7127
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:ODANAH
Mailing Address - State:WI
Mailing Address - Zip Code:54861-0055
Mailing Address - Country:US
Mailing Address - Phone:715-682-7127
Mailing Address - Fax:715-682-7883
Practice Address - Street 1:72772 ELM STREET
Practice Address - Street 2:
Practice Address - City:ODANAH
Practice Address - State:WI
Practice Address - Zip Code:54861-0055
Practice Address - Country:US
Practice Address - Phone:715-682-7127
Practice Address - Fax:715-682-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No253J00000XAgenciesFoster Care Agency