Healthcare Provider Details

I. General information

NPI: 1073530150
Provider Name (Legal Business Name): BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 ST. JOHN DR
NETT LAKE MN
55772
US

IV. Provider business mailing address

5219 SAINT JOHN DR
ORR MN
55771-8232
US

V. Phone/Fax

Practice location:
  • Phone: 218-757-3650
  • Fax:
Mailing address:
  • Phone: 218-757-3650
  • Fax: 218-757-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: CATHERINE CHAVERS
Title or Position: TRIBAL CHAIRMAN
Credential:
Phone: 218-757-3361