Provider Demographics
NPI:1053592089
Name:BAY MILLS INDIAN COMMUNITY
Entity type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-248-8327
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9319
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:906-248-5765
Practice Address - Street 1:12455 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9319
Practice Address - Country:US
Practice Address - Phone:906-248-5527
Practice Address - Fax:906-248-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI231839261QF0400X, 261QF0400X
261QP0904X, 251B00000X, 251S00000X, 252Y00000X, 251J00000X, 261QC1500X, 261QF0050X, 261QH0100X, 261QM0801X, 332800000X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No251J00000XAgenciesNursing Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053592089Medicaid
700A760200Medicare PIN
MI774678200Medicaid
MI774628094Medicaid
MI774657980Medicaid
700A760200Medicare PIN