Provider Demographics
NPI:1770500548
Name:NOTTAWASEPPI HURON BAND OF THE POTAWATOMI
Entity type:Organization
Organization Name:NOTTAWASEPPI HURON BAND OF THE POTAWATOMI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIND
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-729-4422
Mailing Address - Street 1:1474 MNO - BMADZEWEN WAY
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MI
Mailing Address - Zip Code:49052-9602
Mailing Address - Country:US
Mailing Address - Phone:269-729-4422
Mailing Address - Fax:269-729-4460
Practice Address - Street 1:4415 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4800
Practice Address - Country:US
Practice Address - Phone:616-249-0159
Practice Address - Fax:616-249-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18732261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal