Healthcare Provider Details

I. General information

NPI: 1649270901
Provider Name (Legal Business Name): BOIS FORTE RESERVATION TRIBAL COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13071 NETT LAKE ROAD, SUITE B
NETT LAKE MN
55772
US

IV. Provider business mailing address

5219 ST JOHN DRIVE
NETT LAKE MN
55772-8232
US

V. Phone/Fax

Practice location:
  • Phone: 218-757-3295
  • Fax: 218-757-0234
Mailing address:
  • Phone: 218-757-3295
  • Fax: 218-757-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number251S00000X-COMMUNITY
License Number StateMN

VIII. Authorized Official

Name: LYNETTE TAHTINEN
Title or Position: DATA & FINANCE SPECIALIST
Credential: CPCS
Phone: 218-757-3295