Provider Demographics
NPI:1477227239
Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MOAM
Authorized Official - Phone:231-534-7136
Mailing Address - Street 1:2605 N. WEST BAY SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PESHAEBESTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9275
Mailing Address - Country:US
Mailing Address - Phone:231-534-0709
Mailing Address - Fax:
Practice Address - Street 1:2300 N. STALLMAN RD.
Practice Address - Street 2:
Practice Address - City:PESHAWBESTOWN
Practice Address - State:MI
Practice Address - Zip Code:49682-9275
Practice Address - Country:US
Practice Address - Phone:231-534-0709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty