1770819781 NPI number — VIEJAS BAND OF KUMEYAAY INDIANS

Table of content: (NPI 1770819781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770819781 NPI number — VIEJAS BAND OF KUMEYAAY INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIEJAS BAND OF KUMEYAAY INDIANS
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:
1770819781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95826-9110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 VIEJAS GRADE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91901-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-659-2374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BUTZ
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
H
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
619-659-2374

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1770819781 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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