Basic Information
| Provider Information | |||||||||
| NPI: | 1750434395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAULT TRIBE OF CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAULT TRIBAL HEALTH CENTER LABORATORY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2864 ASHMUN ST | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497833740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325200 | ||||||||
| FaxNumber: | 9066325276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2864 ASHMUN ST | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497833740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325200 | ||||||||
| FaxNumber: | 9066325276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 12/27/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CULFA | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9066325200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAULT TRIBE OF CHIPPEWA INDIANS | ||||||||
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| AuthorizedOfficialCredential: | RN MSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | MI | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0A71500 | 01 | MI | BLUE CROSS & BLUE SHIELD | OTHER | 3516048 | 05 | MI | MEDICAID |