NPIMap

Organization Active NPI

Little Traverse Bay Bands of Odawa Indians

  • Federally Qualified Health Center (FQHC)
  • Petoskey, MI
National Provider Identifier
1124052816
Registry record updated Jul 25, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Practice address
1260 Ajijaak Ave
Petoskey, MI 49770-8330
Phone
(231) 242-1700
Fax
(231) 242-1717
NPI assigned
Jul 10, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Christina Dubois
Title
Assistant Health Director
Phone
(231) 242-1611

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1260 Ajijaak Ave
Petoskey, MI 49770-8330

Mailing address

1260 Ajijaak Ave
Petoskey, MI 49770-8330
Phone (231) 242-1700

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20031215000228 MI Part A Provider - Federally Qualified Health Center (FQHC) 8820995368 Practice locations: Petoskey, MI
O20110916000317 MI Part B Supplier - Clinic/Group Practice 8820995368 Receives reassigned benefits from 14 practitioners
Practice locations: Petoskey, MI
O20230208000810 MI Part A Provider - Federally Qualified Health Center (FQHC) 8820995368 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Petoskey, MI

Federally qualified health center certification: CCN 231872

Legal name
LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Doing business as
LTBB OF ODAWA INDIANS HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 15, 2000
Last certification
Jun 15, 2000
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
1260 Ajijaak Ave
Petoskey, MI 49770-8330

Federally qualified health center certification: CCN 231192

Legal name
LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 19, 2023
Last certification
Jan 19, 2023
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
2390 Mitchell Park Dr
Ste D
Petoskey, MI 49770-8965

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

1260 Crane Ave
Petoskey, MI 49770
Phone (231) 242-1700

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Phil Harmon Individual W-2 Managing Employee Jan 1, 2018
Corporate Director Nov 28, 2022
Christina Dubois Individual Corporate Director Nov 28, 2022
Little Traverse Bay Bands of Odawa Indians Organization, Harbor Springs, MI Operational/Managerial Control Jun 28, 1999
Daugherty Johnson Individual Operational/Managerial Control Nov 28, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152489600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753401600000",
    "number": "1124052816",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1260 AJIJAAK AVE",
            "city": "PETOSKEY",
            "state": "MI",
            "postal_code": "497708330",
            "telephone_number": "231-242-1700",
            "fax_number": "231-242-1717"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1260 AJIJAAK AVE",
            "city": "PETOSKEY",
            "state": "MI",
            "postal_code": "497708330",
            "telephone_number": "231-242-1700",
            "fax_number": "231-242-1717"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-10",
        "last_updated": "2025-07-25",
        "certification_date": "2025-07-25",
        "status": "A",
        "authorized_official_last_name": "DUBOIS",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_title_or_position": "ASSISTANT HEALTH DIRECTOR",
        "authorized_official_telephone_number": "231-242-1611"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Petoskey, MI

Sources for this page

Verify at the official NPI Registry.