1952685588 NPI number — MATCH-E-BE-NASH-SHE-WISH BAND OF POTTAWATOMI INDIANS

Table of content: (NPI 1952685588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952685588 NPI number — MATCH-E-BE-NASH-SHE-WISH BAND OF POTTAWATOMI INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATCH-E-BE-NASH-SHE-WISH BAND OF POTTAWATOMI INDIANS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GUN LAKE TRIBE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952685588
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2880 MISSION DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-397-1760
Provider Business Mailing Address Fax Number:
269-397-1763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2880 MISSION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49344-9580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-397-1760
Provider Business Practice Location Address Fax Number:
269-397-1763
Provider Enumeration Date:
09/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WESAW
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
269-397-1760

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com