Provider Demographics
NPI:1972666469
Name:BOIS FORTE MEDICAL CLINIC
Entity Type:Organization
Organization Name:BOIS FORTE MEDICAL CLINIC
Other - Org Name:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRADI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:218-757-3650
Mailing Address - Street 1:5219 ST JOHN DR
Mailing Address - Street 2:
Mailing Address - City:NETT LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55772-8111
Mailing Address - Country:US
Mailing Address - Phone:218-757-3650
Mailing Address - Fax:218-757-0234
Practice Address - Street 1:5219 ST JOHN DR
Practice Address - Street 2:
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55772
Practice Address - Country:US
Practice Address - Phone:218-757-3650
Practice Address - Fax:218-757-0234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOIS FORTE TRIBAL GOVERNMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261489-2261QH0100X
332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63G35BOOtherBCBS
MN0104492OtherMEDICA
MN177515400Medicaid