Provider Demographics
NPI:1366409237
Name:BAY MILLS INDIAN COMMUNITY
Entity type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HHS DIRCTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-248-8315
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9327
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:906-248-5765
Practice Address - Street 1:204 E PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2054
Practice Address - Country:US
Practice Address - Phone:906-248-5527
Practice Address - Fax:906-248-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774678200Medicaid