Healthcare Provider Details

I. General information

NPI: 1952388175
Provider Name (Legal Business Name): BAY MILLS INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12455 W LAKESHORE DR
BRIMLEY MI
49715-9327
US

IV. Provider business mailing address

12455 W LAKESHORE DR
BRIMLEY MI
49715-9327
US

V. Phone/Fax

Practice location:
  • Phone: 906-248-5527
  • Fax: 906-248-5765
Mailing address:
  • Phone: 906-248-5527
  • Fax: 906-248-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: AUDREY BREAKIE
Title or Position: HHS DIRECTOR
Credential:
Phone: 906-248-8327