| Organization Name: | LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS |
| NPI Number: | 1124052816 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TERRY SAMUELS (MEDICAL DIRECTOR) |
| Mailing Address: | 1250 Lears Rd. Petoskey |
| State: | MI US |
| Postal Code: | 497708774 |
| Phone Number: | 2312421700 |
| Fax Number: | 2312421717 |
| NPI Enumeration Date: | 07/10/2006 |
| NPI Last Update Date: | 01/29/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |