Healthcare Provider Details

I. General information

NPI: 1174796411
Provider Name (Legal Business Name): KEWEENAW BAY INDIAN COMMUNITY SUBSTANCE ABUSE PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16025 BREWERY RD
LANSE MI
49946-8092
US

IV. Provider business mailing address

PO BOX 69
LANSE MI
49946-0069
US

V. Phone/Fax

Practice location:
  • Phone: 906-524-4411
  • Fax: 906-524-4415
Mailing address:
  • Phone: 906-524-4411
  • Fax: 906-524-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0700001
License Number StateMI

VIII. Authorized Official

Name: MR. JERRY LEE CURTIS
Title or Position: ADMINISTRATOR
Credential: CAC-1
Phone: 906-524-4411