1952518946 NPI number — SHOSHONE BANNOCK TRIBES

Table of content: (NPI 1952518946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952518946 NPI number — SHOSHONE BANNOCK TRIBES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOSHONE BANNOCK TRIBES
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:
SHOSHONE BANNOCK CLINIC PODIATRY GROUP
Provider Other Organization Name Type Code:
3
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:
1952518946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
PIMA DRIVE
Provider Business Mailing Address City Name:
FORT HALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83203-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-478-3994
Provider Business Mailing Address Fax Number:
208-478-3943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 MISSION ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-5421
Provider Business Practice Location Address Fax Number:
208-238-5462
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MENDEZ
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
TRIBAL HEALTH DIRECTOR
Authorized Official Telephone Number:
208-478-3994

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8066486 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com