Basic Information
| Provider Information | |||||||||
| NPI: | 1114071578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LVD HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | WATERSMEET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499690009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063584588 | ||||||||
| FaxNumber: | 9063584118 | ||||||||
| Practice Location | |||||||||
| Address1: | N5241 US HIGHWAY 45 | ||||||||
| Address2: | |||||||||
| City: | WATERSMEET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499695115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063584588 | ||||||||
| FaxNumber: | 9063584118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LAC VIEUX DESERT TRIBAL CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 9063584577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | OB74513 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 1114071578 | 05 | MI | MEDICAID |