1639210370 NPI number — OMAK TRIBAL HEALTH CLINIC

Table of content: (NPI 1639210370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639210370 NPI number — OMAK TRIBAL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMAK TRIBAL HEALTH CLINIC
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:
1639210370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 71
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NESPELEM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99155-0071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-634-2900
Provider Business Mailing Address Fax Number:
509-634-2990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 BENTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98841-0962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-634-2900
Provider Business Practice Location Address Fax Number:
509-634-2990
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MISIASZEK
Authorized Official First Name:
YVONNE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
509-634-2900

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6026850 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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