1629078274 NPI number — KLAMATH TRIBAL HEALTH & FAMILY SERVICES

Table of content: (NPI 1629078274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629078274 NPI number — KLAMATH TRIBAL HEALTH & FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KLAMATH TRIBAL HEALTH & FAMILY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629078274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3949 SOUTH 6TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97603-4746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-882-1487
Provider Business Mailing Address Fax Number:
541-882-8277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 CHILOQUIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILOQUIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-783-2438
Provider Business Practice Location Address Fax Number:
541-783-3273
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MENDEZ
Authorized Official First Name:
NIKOWA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
COMPLIANCE ADMINISTRATOR
Authorized Official Telephone Number:
541-882-1487

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 129861 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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