Basic Information
| Provider Information | |||||||||
| NPI: | 1780737403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAULT TRIBE OF CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MUNISING TRIBAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874614 | ||||||||
| FaxNumber: | 9063874727 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874614 | ||||||||
| FaxNumber: | 9063874727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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 | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN MSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 231843 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 231843 | 01 | UGS | OTHER |