Provider Demographics
NPI:1477605137
Name:SAULT TRIBE OF CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:SAULT TRIBE OF CHIPPEWA INDIANS
Other - Org Name:KINROSS COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CULFA
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MSN
Authorized Official - Phone:906-632-5200
Mailing Address - Street 1:16877 S WATER TOWER DR
Mailing Address - Street 2:
Mailing Address - City:KINCHELOE
Mailing Address - State:MI
Mailing Address - Zip Code:49788-1507
Mailing Address - Country:US
Mailing Address - Phone:906-495-5745
Mailing Address - Fax:906-495-5940
Practice Address - Street 1:16877 S WATER TOWER DR
Practice Address - Street 2:
Practice Address - City:KINCHELOE
Practice Address - State:MI
Practice Address - Zip Code:49788-1507
Practice Address - Country:US
Practice Address - Phone:906-495-5745
Practice Address - Fax:906-495-5940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAULT TRIBE OF CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231881261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
231881OtherFQHC FACILITY NUMBER