NPIMap

Organization Active NPI

Thunder Bay Community Health Service, Inc

Doing business as Johannesburg-Lewiston Area Schools

  • Federally Qualified Health Center (FQHC)
  • Johannesburg, MI
National Provider Identifier
1760864763
Registry record updated Jul 30, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Doing business as
Johannesburg-Lewiston Area Schools
Practice address
10854 M 32 E
Johannesburg, MI 49751-9622
Phone
(989) 354-2197
Fax
(989) 356-6524
NPI assigned
Jun 25, 2015
Last updated
Jul 30, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2026

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

Authorized official

Name
Doug Kreis
Title
Interim Ceo
Phone
(989) 731-4420

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
General Practice Dentistry 1223G0001X

Addresses

Primary practice location

10854 M 32 E
Johannesburg, MI 49751-9622

Mailing address

PO Box 427
Hillman, MI 49746-0427

Other names 1

  • Johannesburg-Lewiston Area Schools Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220316000576 MI Part A Provider - Federally Qualified Health Center (FQHC) 0143296772 Practice locations: Johannesburg, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760864763. Details of each certification follow.

Federally qualified health center certification: CCN 231178

Legal name
THUNDER BAY COMMUNITY HEALTH SERVICE INC
Doing business as
JOHANNESBURG-LEWISTON AREA SCHOOLS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 16, 2022
Last certification
Mar 16, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 7, 1980 in MI
Enrollment address
10854 M 32 E
Johannesburg, MI 49751-9622

Other NPIs with the same Medicare PAC ID 10

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

National Provider Directory

National Provider Directory

Locations

10854 M 32 E
Johannesburg, MI 49751
Phone (989) 785-4855

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Rodney D Fullerton Individual Corporate Director Mar 1, 2022
Shanna Johnson Individual Corporate Director Mar 1, 2022
Michael Bruce Fairbanks Individual Corporate Director Mar 1, 2022
Nina Kennard Individual Corporate Director Mar 1, 2022
Beach Hall Individual Corporate Director Mar 1, 2022
Benjamin Bolser Individual Corporate Director Mar 1, 2022
Jacquelyn McIntire Individual Corporate Director Mar 1, 2022
Richard D Bates Individual Corporate OfficerCeo Mar 3, 2023 100%
W-2 Managing EmployeeCeo Mar 3, 2023 100%
Carrie Lohman Individual Corporate Director Mar 1, 2022
Mike Wurtsmith Individual Corporate Director Mar 1, 2022
Aldean Moe Individual Corporate Director Mar 1, 2022
Susan Stacey Individual Corporate Director Mar 1, 2022
Tommie Wolff Individual Corporate Director Mar 1, 2022
Julie a Kendrick Individual Corporate Director Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1435190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1785369600000",
    "number": "1760864763",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 427",
            "city": "HILLMAN",
            "state": "MI",
            "postal_code": "497460427"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10854 M 32 E",
            "city": "JOHANNESBURG",
            "state": "MI",
            "postal_code": "497519622",
            "telephone_number": "989-354-2197",
            "fax_number": "989-356-6524"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THUNDER BAY COMMUNITY HEALTH SERVICE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-25",
        "last_updated": "2026-07-30",
        "certification_date": "2026-07-30",
        "status": "A",
        "authorized_official_last_name": "KREIS",
        "authorized_official_first_name": "DOUG",
        "authorized_official_title_or_position": "INTERIM CEO",
        "authorized_official_telephone_number": "989-731-4420"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Johannesburg-Lewiston Area Schools",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Johannesburg-Lewiston Area Schools",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Johannesburg, MI

Sources for this page

Verify at the official NPI Registry.