1144222761 NPI number — DUCKWATER SHOSHONE TRIBE

Table of content: (NPI 1144222761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144222761 NPI number — DUCKWATER SHOSHONE TRIBE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUCKWATER SHOSHONE TRIBE
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:
DUCKWATER HEALTH CLINIC
Provider Other Organization Name Type Code:
5
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:
1144222761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 140087
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUCKWATER
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89314-0087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-863-0222
Provider Business Mailing Address Fax Number:
775-863-0142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 DUCKWATER FALLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUCKWATER
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89314-0087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-863-0222
Provider Business Practice Location Address Fax Number:
775-863-0142
Provider Enumeration Date:
08/12/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILLETT
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
TRIBAL MANAGER CHAIRMAN
Authorized Official Telephone Number:
775-863-0227

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004712001 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003112002 . This is a "HEALTHY KIDS SCREENING" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".