1093931107 NPI number — FORT BIDWELL INDIAN COMMUNITY

Table of content: (NPI 1093931107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093931107 NPI number — FORT BIDWELL INDIAN COMMUNITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT BIDWELL INDIAN COMMUNITY
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:
6
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:
1093931107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BIDWELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96112-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-279-6194
Provider Business Mailing Address Fax Number:
530-279-6288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 MEE THEE UH ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BIDWELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-279-6194
Provider Business Practice Location Address Fax Number:
530-279-6288
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
530-279-6194

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: THP70973F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: O5D0692143 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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