Provider Demographics
NPI:1871713321
Name:BOIS FORTE RESERVATION TRIBAL COUNCIL
Entity type:Organization
Organization Name:BOIS FORTE RESERVATION TRIBAL COUNCIL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DATA & FINANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHTINEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:218-757-3295
Mailing Address - Street 1:5219 ST JOHN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NETT LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55772-8232
Mailing Address - Country:US
Mailing Address - Phone:218-757-3295
Mailing Address - Fax:218-757-0234
Practice Address - Street 1:13071 NETT LAKE ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55772
Practice Address - Country:US
Practice Address - Phone:218-757-3295
Practice Address - Fax:218-757-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN004218800Other101YA0400X