Provider Demographics
NPI:1174796411
Name:KEWEENAW BAY INDIAN COMMUNITY SUBSTANCE ABUSE PROGRAMS
Entity type:Organization
Organization Name:KEWEENAW BAY INDIAN COMMUNITY SUBSTANCE ABUSE PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:CAC-1
Authorized Official - Phone:906-524-4411
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-0069
Mailing Address - Country:US
Mailing Address - Phone:906-524-4411
Mailing Address - Fax:906-524-4415
Practice Address - Street 1:16025 BREWERY RD
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8092
Practice Address - Country:US
Practice Address - Phone:906-524-4411
Practice Address - Fax:906-524-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0700001324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility