Provider Demographics
NPI:1750434395
Name:SAULT TRIBE OF CHIPPEWA INDIANS
Entity type:Organization
Organization Name:SAULT TRIBE OF CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CULFA
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN
Authorized Official - Phone:906-632-5200
Mailing Address - Street 1:2864 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3740
Mailing Address - Country:US
Mailing Address - Phone:906-632-5200
Mailing Address - Fax:906-632-5276
Practice Address - Street 1:2864 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3740
Practice Address - Country:US
Practice Address - Phone:906-632-5200
Practice Address - Fax:906-632-5276
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAULT TRIBE OF CHIPPEWA INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A71500OtherBLUE CROSS & BLUE SHIELD
MI3516048Medicaid
MI3516048Medicaid