Provider Demographics
NPI:1497833271
Name:POKAGON BAND OF POTAWATOMI INDIANS
Entity Type:Organization
Organization Name:POKAGON BAND OF POTAWATOMI INDIANS
Other - Org Name:POKAGON HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GATTIES
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:269-782-4141
Mailing Address - Fax:269-783-1236
Practice Address - Street 1:32652 KNO DRIVE
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-0180
Practice Address - Country:US
Practice Address - Phone:269-782-4141
Practice Address - Fax:269-783-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)