Provider Demographics
NPI:1649270901
Name:BOIS FORTE RESERVATION TRIBAL COUNCIL
Entity type:Organization
Organization Name:BOIS FORTE RESERVATION TRIBAL COUNCIL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DATA & FINANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHTINEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:218-757-3295
Mailing Address - Street 1:5219 ST JOHN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NETT LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55772-8232
Mailing Address - Country:US
Mailing Address - Phone:218-757-3295
Mailing Address - Fax:218-757-0235
Practice Address - Street 1:13071 NETT LAKE ROAD, SUITE B
Practice Address - Street 2:
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55772
Practice Address - Country:US
Practice Address - Phone:218-757-3295
Practice Address - Fax:218-757-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251S00000X-COMMUNITY251S00000X
332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03385Medicare PIN
MN680001806Medicare PIN