Provider Demographics
NPI:1871272583
Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Entity type:Organization
Organization Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:DUBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-878-0419
Mailing Address - Street 1:1260 AJIJAAK AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8330
Mailing Address - Country:US
Mailing Address - Phone:231-878-0419
Mailing Address - Fax:
Practice Address - Street 1:2390 MITCHELL PARK DR STE D
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-242-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty