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FQHC638421 LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS (Active)
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Main Details
Name
LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Subdivision Name
LITTLE TRAVERSE BAY BANDS HEALTH DEPARTMENT
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638421
Additional Details
Current Program Status
Active
Registration Date
10/1/1999
Participating Start Date
10/1/1999
Participating Approval Date
12/21/2004
Last Recertification Date
2/14/2025
Contacts
Authorizing Official
LTBB of Odawa Indians
Daugherty Johnson, Executive Director
(231) 242-1420
Primary Contact
Little Traverse Bay Bands of Odawa Indians Health Clinic
Alyssa J Hromika, Dr
(231) 242-1743
Addresses
Street Address
1260 Ajijaak Avenue
PETOSKEY, MI 49770
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
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12/20/04 UPDATED ADDR (WAS 1345 US 31 N., P.O. BOX 246, PETOSKEY, MICHIGAN 49770);
08/03/2010
May 2025
May 2025
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