Basic Information
| Provider Information | |||||||||
| NPI: | 1346247947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIAN HEALTH COUNCIL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4058 WILLOWS ROAD | ||||||||
| Address2: | |||||||||
| City: | ALPINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
| FaxNumber: | 6196593138 | ||||||||
| Practice Location | |||||||||
| Address1: | 4058 WILLOWS RD | ||||||||
| Address2: | |||||||||
| City: | ALPINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
| FaxNumber: | 6196593140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6194451188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | ZZZ58086Z | 01 | BLUE SHIELD OF CALIFORNIA | OTHER | THP70010F | 05 | CA | MEDICAID | HAP70010F | 01 | CA | FAMILY PACT | OTHER | W7576A | 01 | CA | MEDICARE | OTHER |