1497870372 NPI number — CONFEDERATE TRIBES OF THE COLVILLE RESERVATION

Table of content: (NPI 1497870372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497870372 NPI number — CONFEDERATE TRIBES OF THE COLVILLE RESERVATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONFEDERATE TRIBES OF THE COLVILLE RESERVATION
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:
CNCHC INCHELIUM COMMUNITY HEALTH CENTER
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:
1497870372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 SHORTCUT ROAD
Provider Second Line Business Mailing Address:
PO BOX 290
Provider Business Mailing Address City Name:
INCHELIUM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99138-0290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-722-7006
Provider Business Mailing Address Fax Number:
509-722-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 SHORTCUT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INCHELIUM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99138-0290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-722-7006
Provider Business Practice Location Address Fax Number:
509-722-7021
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
509-722-7006

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: 7085426 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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