Basic Information
| Provider Information | |||||||||
| NPI: | 1588115018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAD RIVER BAND OF LAKE SUPERIOR TRIBE OF CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAD RIVER HEALTH AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827133 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Practice Location | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827133 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PNCC NURSE | ||||||||
| AuthorizedOfficialTelephone: | 7156827133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 160502 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
No ID Information.