Basic Information
| Provider Information | |||||||||
| NPI: | 1144581398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAD RIVER HONORING OUR CHILDREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827137 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Practice Location | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827137 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHS ADMINISTRATOR/CLINIC BILLING | ||||||||
| AuthorizedOfficialTelephone: | 7156827137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAD RIVER BAND OF LAKE SUPERIOR CHIPPEWA INDIANS | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.