Healthcare Provider Details

I. General information

NPI: 1669692554
Provider Name (Legal Business Name): BAY MILLS INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12124 W LAKESHORE DR
BRIMLEY MI
49715-9319
US

IV. Provider business mailing address

12124 W LAKESHORE DR PO BOX 138
BRIMLEY MI
49715-9319
US

V. Phone/Fax

Practice location:
  • Phone: 906-248-3241
  • Fax: 906-248-5765
Mailing address:
  • Phone: 906-248-3241
  • Fax: 906-248-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5301007314
License Number StateMI

VIII. Authorized Official

Name: MIKE BROOKS
Title or Position: CFO
Credential:
Phone: 906-248-3241