Provider Demographics
NPI:1336232289
Name:KEWEENAW BAY INDIAN COMMUNITY
Entity type:Organization
Organization Name:KEWEENAW BAY INDIAN COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P
Authorized Official - Phone:906-353-4542
Mailing Address - Street 1:102 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:BARAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49908-9673
Mailing Address - Country:US
Mailing Address - Phone:906-353-4542
Mailing Address - Fax:906-353-8799
Practice Address - Street 1:102 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908-9673
Practice Address - Country:US
Practice Address - Phone:906-353-4542
Practice Address - Fax:906-353-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI231845261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231845Medicare ID - Type Unspecified