MEDICARE: BOIS FORTE RESERVATION TRIBAL COUNCIL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036862800	OTHER	MN	101YA0400X

General Provider Information

NPI Number	:	1538371117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOIS FORTE RESERVATION TRIBAL COUNCIL

Provider Business Mailing Address
First Line	:	5219 ST JOHN DRIVE
Second Line	:
City	:	NETT LAKE
State	:	MN
Zip	:	55772-8232
Country	:	US
Telephone Number	:	218-757-3295
Fax Number	:	218-757-0234

Provider Business Practice Location Address
First Line	:	1195 COUNTY ROAD 77
Second Line	:
City	:	TOWER
State	:	MN
Zip	:	55790
Country	:	US
Telephone Number	:	218-757-0111
Fax Number	:	218-757-0109

Authorized Official
Title or Position	:	DATA & FINANCE SPECIALIST
Name	:	LYNETTE TAHTINEN
Credential	:	CPCS
Telephone Number	:	218-757-3295

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	05/15/2018

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