Provider Demographics
NPI:1073711057
Name:BAY MILLS INDIAN COMMUNITY
Entity Type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HHS DIRECTOR
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:906-248-8327
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9319
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:906-248-2496
Practice Address - Street 1:12455 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9319
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:2007-07-11
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073711057Medicaid
MIMI9748OtherMEDICARE
231839Medicare PIN