Provider Demographics
NPI:1205939469
Name:SAGINAW CHIPPEWA INDIAN TRIBE
Entity type:Organization
Organization Name:SAGINAW CHIPPEWA INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLOUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-775-4200
Mailing Address - Street 1:2591 S LEATON RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-775-4924
Mailing Address - Fax:989-775-4990
Practice Address - Street 1:2591 S LEATON RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-775-4924
Practice Address - Fax:989-775-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBN2651861333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C707520OtherBCBS
MI2348844OtherNCPDP
MI2754368Medicaid