Basic Information
| Provider Information | |||||||||
| NPI: | 1346465101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COWLITZ INDIAN TRIBE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COWLITZ INDIAN TRIBAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605758275 | ||||||||
| FaxNumber: | 3605751950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605758275 | ||||||||
| FaxNumber: | 3605751950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | SHAVON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3603539431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7122898 | 05 | WA | MEDICAID |