Healthcare Provider Details

I. General information

NPI: 1225185705
Provider Name (Legal Business Name): POKAGON BAND OF POTAWATOMI INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32652 KNO
DOWAGIAC MI
49047
US

IV. Provider business mailing address

PO BOX 180
DOWAGIAC MI
49047-0180
US

V. Phone/Fax

Practice location:
  • Phone: 269-782-4141
  • Fax: 269-782-1236
Mailing address:
  • Phone:
  • Fax: 269-782-1236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MATT CLAY
Title or Position: DIRECTOR OF HEALTH SERVICES
Credential:
Phone: 269-782-4141