Basic Information
| Provider Information | |||||||||
| NPI: | 1447264866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEECH LAKE TRIBAL COUNCIL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEECH LAKE AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 6TH ST. NW | ||||||||
| Address2: | SUITE E | ||||||||
| City: | CASS LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183356363 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | TRIBAL COUNCIL | ||||||||
| AuthorizedOfficialFirstName: | LEECH LAKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | TRIBAL COUNCIL MEMBERS | ||||||||
| AuthorizedOfficialTelephone: | 2183358200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 83080LE | 01 | MN | BCBS | OTHER |