| Details | Last Recertification Date | Update | Recertification | 1/31/2024 12:44:29 PM | 2/19/2025 11:58:02 AM | 2/19/2025 11:58 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1669227203 | 5/15/2024 3:49 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 5/15/2024 3:49 PM |
| Contacts | Authorizing Official | Update | Change Request | Winslow, Doris
Executive Assistant to the Tribal Manager
Grand Traverse Band of Ottawa & Chippewa Indians
2315347965 | ZOTIGH, SONYA
Health Administrator
GTB
2315347241 | 5/15/2024 3:49 PM |
| Contacts | Primary Contact | Update | PC Change Request | Chambers, Loi
Assistant Health Administrator
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | Hines, Kimberly Jane
Chief pharmacist
Grand Traverse Band of Ottawa and Chippewa Indians Pharmacy
2314924996 | 5/14/2024 3:02 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Winslow, Doris
Interim Health Director
Grand Traverse Band of Ottawa & Chippewa Indians
2315347965 | Winslow, Doris
Executive Assistant to the Tribal Manager
Grand Traverse Band of Ottawa & Chippewa Indians
2315347965 | 1/31/2024 12:53 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2023 9:21:33 AM | 1/31/2024 12:44:29 PM | 1/31/2024 12:44 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 9:55:47 AM | 1/31/2023 9:21:33 AM | 1/31/2023 9:21 AM |
| Contacts | Authorizing Official | Update | Change Request | Pendharkar, Soumit
Health Administrator
Grand Traverse Band of Ottawa and Chippewa Indians
2315347241 | Winslow, Doris
Interim Health Director
Grand Traverse Band of Ottawa & Chippewa Indians
2315347965 | 1/23/2023 7:35 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2021 2:11:22 PM | 1/31/2022 9:55:47 AM | 1/31/2022 9:55 AM |
| Contacts | Primary Contact | Update | Recertification | Bussey, Ruth A
Health Director
Grand Traverse Band of Ottawa & Chippewa Indians
2315347201 | Chambers, Loi
Assistant Health Administrator
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | 2/8/2021 2:11 PM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 2:58:39 PM | 2/8/2021 2:11:22 PM | 2/8/2021 2:11 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Chambers, Loi
Optical Technician-DOS
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | Pendharkar, Soumit
Health Administrator
Grand Traverse Band of Ottawa and Chippewa Indians
2315347241 | 1/30/2020 7:51 AM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2019 11:15:17 AM | 1/28/2020 2:58:39 PM | 1/28/2020 2:58 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2018 10:37:30 AM | 2/1/2019 11:15:17 AM | 2/1/2019 11:15 AM |
| Contacts | Primary Contact | Update | Recertification | Chambers, Loi
Optical Technician-DOS
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | Bussey, Ruth A
Health Director
Grand Traverse Band of Ottawa & Chippewa Indians
2315347201 | 2/7/2018 10:37 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2017 12:00:00 AM | 2/7/2018 10:37:30 AM | 2/7/2018 10:37 AM |
| Contacts | Authorizing Official | Update | | Chambers, Loi
Optical Technician-DOS
2315347477 | Chambers, Loi
Optical Technician-DOS
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | 2/7/2018 10:26 AM |
| Contacts | Primary Contact | Update | | Chambers, Loi
Optical Technician-DOS
2315347477 | Chambers, Loi
Optical Technician-DOS
Grand Traverse Band of Ottawa & Chippewa Indians
2315347477 | 2/7/2018 10:26 AM |
| Contacts | Signed By | Update | | Chambers, Loi
Division IV Business Manager
2315347477 | Chambers, Loi
Division IV Business Manager
GRAND TRAVERSE BAND OF OTTAWA & CHIPPEWA INDIANS
2315347477 | 1/9/2018 1:40 PM |
| Addresses | Main Address | Insert | | |
2300 N Stallman Rd
Peshawbestown, MI 49682 | 2/8/2017 4:41 PM |
| Contacts | Authorizing Official | Insert | | | Chambers, Loi
Optical Technician-DOS
2315347477 | 2/8/2017 4:41 PM |
| Contacts | Primary Contact | Insert | | | Chambers, Loi
Optical Technician-DOS
2315347477 | 2/8/2017 4:41 PM |
| Contacts | Signed By | Insert | | | Chambers, Loi
Division IV Business Manager
2315347477 | 2/8/2017 4:41 PM |
| Details | Last Recertification Date | Update | | 2/25/2016 12:00:00 AM | 2/8/2017 12:00:00 AM | 2/8/2017 4:41 PM |
| Details | Last Recertification Date | Update | | 2/3/2015 12:00:00 AM | 2/25/2016 12:00:00 AM | 2/25/2016 8:58 AM |
| Details | Last Recertification Date | Update | | 2/13/2014 12:00:00 AM | 2/3/2015 12:00:00 AM | 2/3/2015 2:46 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/13/2014 12:00:00 AM | 2/13/2014 9:52 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/20/2013 7:16 AM |
| Details | 340B ID | Update | | IS-EMG-FQHC638529 | FQHC638527 | 9/27/2012 10:00 AM |
| Dates | Participating Approval Date | Update | | | 9/27/2012 12:00:00 AM | 9/27/2012 10:00 AM |
| Details | State | Update | | Pending | Active | 9/27/2012 10:00 AM |
| Dates | Start Date | Update | | | 10/1/2012 12:00:00 AM | 9/27/2012 10:00 AM |
| Details | 340B ID | Update | | EMG09272012 | IS-EMG-FQHC638529 | 9/26/2012 2:43 PM |
| Details | 340B ID | Update | | ONLINE_REG | EMG09272012 | 9/24/2012 10:52 AM |
| Details | Last Recertification Date | Insert | | | | 8/29/2012 4:56 PM |
| Details | Grant Number | Insert | | | | 8/29/2012 4:56 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 8/29/2012 4:56 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 8/29/2012 4:56 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 8/29/2012 4:56 PM |
| Details | Medicare Provider Number | Insert | | | | 8/29/2012 4:56 PM |
| Details | Entity Name | Insert | | | Grand Traverse Band of Ottawa and Chiippewa Indians | 8/29/2012 4:56 PM |
| Details | Program Code | Insert | | | FQHC638 | 8/29/2012 4:56 PM |
| Details | Entity Subname | Insert | | | Grand Traverse Band Family Health Clinic | 8/29/2012 4:56 PM |
| Dates | Participating Approval Date | Insert | | | | 8/29/2012 4:56 PM |
| Details | State | Insert | | | Pending | 8/29/2012 4:56 PM |
| Dates | Registration Date | Insert | | | 8/29/2012 12:00:00 AM | 8/29/2012 4:56 PM |
| Dates | Signed By Date | Insert | | | 8/29/2012 12:00:00 AM | 8/29/2012 4:56 PM |
| Dates | Start Date | Insert | | | | 8/29/2012 4:56 PM |
| Terminations | Termination Comments | Insert | | | | 8/29/2012 4:56 PM |
| Terminations | Termination Date | Insert | | | | 8/29/2012 4:56 PM |
| Terminations | Termination Effective Date | Insert | | | | 8/29/2012 4:56 PM |
| Terminations | Termination Reason | Insert | | | | 8/29/2012 4:56 PM |