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Bay Mills Indian Community

Organization Active NPI Federally Qualified Health Center (FQHC) · Sault Sainte Marie, MI

NPI 1366409237 · NPPES record last updated Jun 20, 2023

Key facts

NPI
1366409237
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
BAY MILLS INDIAN COMMUNITY
Practice address
204 E Portage Ave
Sault Sainte Marie, MI 49783-2054
Phone
(906) 248-5527
Fax
(906) 248-5765
NPI assigned
Apr 26, 2006
Organization subpart
No

Authorized official

Name
Audrey Breakie
Title
HHS Dirctor
Phone
(906) 248-8315

Owners & managing parties with NPI records 3

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

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs with the same Medicare PAC ID 3

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

Corporate family (same tax ID) 9

Organizations that report the same tax identification number in the National Provider Directory.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 14

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled in MI

Federally qualified health center certification: CCN C71010

Legal name
BAY MILLS INDIAN COMMUNITY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 27, 2023
Last certification
Dec 27, 2023
Ownership / control type
For profit – corporation
Organization structure
Government · Non-profit
Incorporated
Jan 1, 2001 in MI
Enrollment address
204 E Portage Ave
Sault Sainte Marie, MI 49783-2054

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Lucy Dewildt
Individual 		Corporate Director
Assistant HHS Director		 Sep 1, 2022 50%
W-2 Managing Employee
Health & Human Services Director		 Jul 8, 2024 100%
Abby L Kaunisto
Individual 		W-2 Managing Employee
Clinic Coordinator		 Jul 5, 2015
Bay Mills Indian Community
Organization · Brimley, MI 		5% Or Greater Direct Ownership Interest Dec 13, 2023 100%

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Bay Mills Indian Community
Brimley, MI · CCN 231839		 Federally qualified health center Operational/Managerial Control Jan 1, 1993

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20240104002493 MI Part a Provider - Federally Qualified Health Center (FQHC) 8729079918 Practice locations: Sault Sainte Marie, MI

National Provider Directory

Tax ID family
Bay Mills Health Center (10 organizations share this tax ID)

Locations

204 E Portage Ave
Sault Sainte Marie, MI 49783
Phone (906) 248-5527

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

204 E Portage Ave
Sault Sainte Marie, MI 49783-2054

Mailing address

12455 W Lakeshore Dr
Brimley, MI 49715-9327
Phone (906) 248-5527

Other names

  • Mitigoons Dental Doing business as

Other providers in Sault Sainte Marie, MI

All providers in Sault Sainte Marie, MI · Federally Qualified Health Center (FQHC) in Michigan

Sources for this page

Verify at the official NPI Registry.