Provider Demographics
NPI:1467131409
Name:LITTLE RIVER BAND OF OTTAWA INDIANS
Entity Type:Organization
Organization Name:LITTLE RIVER BAND OF OTTAWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:B
Authorized Official - Last Name:WEVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-398-6852
Mailing Address - Street 1:2840 ORCHARD HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9781
Mailing Address - Country:US
Mailing Address - Phone:231-398-6852
Mailing Address - Fax:
Practice Address - Street 1:2840 ORCHARD HWY STE 2
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9781
Practice Address - Country:US
Practice Address - Phone:231-398-6852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)