Provider Demographics
NPI:1326005273
Name:BAY MILLS INDIAN COMMUNITY
Entity type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HHS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-248-8327
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9327
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:
Practice Address - Street 1:3406 S PINE VILLAGE RD
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9324
Practice Address - Country:US
Practice Address - Phone:906-248-2021
Practice Address - Fax:906-248-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47041823843416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
590015176OtherMEDICARE RAILROAD
209255OtherMULTI-PLAN
MI1326005273Medicaid
590A700080OtherBLUE CROSS BLUE SHIELD
900020355OtherPRIORITY HEALTH