Healthcare Provider Details

I. General information

NPI: 1336232289
Provider Name (Legal Business Name): KEWEENAW BAY INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

IV. Provider business mailing address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

V. Phone/Fax

Practice location:
  • Phone: 906-353-4542
  • Fax: 906-353-8799
Mailing address:
  • Phone: 906-353-4542
  • Fax: 906-353-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number231845
License Number StateMI

VIII. Authorized Official

Name: JOEL BRUCE MILLS
Title or Position: MEDICAL BILLING CLERK
Credential: CCS-P
Phone: 906-353-4542