=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750434395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAULT TRIBE OF CHIPPEWA INDIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 12/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2864 ASHMUN ST
-----------------------------------------------------
City | SAULT SAINTE MARIE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49783-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-632-5200
-----------------------------------------------------
Fax | 906-632-5276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2864 ASHMUN ST
-----------------------------------------------------
City | SAULT SAINTE MARIE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49783-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-632-5200
-----------------------------------------------------
Fax | 906-632-5276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH DIRECTOR
-----------------------------------------------------
Name | BONNIE L CULFA
-----------------------------------------------------
Credential | RN MSN
-----------------------------------------------------
Telephone | 906-632-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 23D0674935
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------