Basic Information
| Provider Information | |||||||||
| NPI: | 1851902399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOKAOGON CHIPPEWA COMMUNITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | NIEFT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7154876402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.