Basic Information
| Provider Information | |||||||||
| NPI: | 1871713321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOIS FORTE RESERVATION TRIBAL COUNCIL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOIS FORTE HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 ST JOHN DRIVE | ||||||||
| Address2: | |||||||||
| City: | NETT LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557728232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187573295 | ||||||||
| FaxNumber: | 2187570234 | ||||||||
| Practice Location | |||||||||
| Address1: | 13071 NETT LAKE ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NETT LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187573295 | ||||||||
| FaxNumber: | 2187570234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAHTINEN | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DATA & FINANCE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2187573295 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 004218800 | 01 | MN | 101YA0400X | OTHER |