Provider Demographics
NPI:1689387821
Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Entity Type:Organization
Organization Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANIMIKWAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-242-1700
Mailing Address - Street 1:2390 MITCHELL PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2390 MITCHELL PARK DR STE D
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-242-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588108260Medicaid