Provider Demographics
NPI:1225185705
Name:POKAGON BAND OF POTAWATOMI INDIANS
Entity Type:Organization
Organization Name:POKAGON BAND OF POTAWATOMI INDIANS
Other - Org Name:POKAGON BAND HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-782-4141
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-0180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:269-782-1236
Practice Address - Street 1:32652 KNO
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047
Practice Address - Country:US
Practice Address - Phone:269-782-4141
Practice Address - Fax:269-782-1236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POKAGON BAND OF POTAWATOMI INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-05
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty