Provider Demographics
NPI:1659680718
Name:HO CHUNK NATION
Entity type:Organization
Organization Name:HO CHUNK NATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER NETWORK MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-284-9851
Mailing Address - Street 1:N6520 LUMBERJACK GUY RD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5405
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:715-284-5150
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-356-1251
Practice Address - Fax:608-356-7122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HO CHUNK NATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-06
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1413261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1413OtherSTATE CERTIFICATION