Basic Information
| Provider Information | |||||||||
| NPI: | 1376681452 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKAMA INDIAN HEALTH SERVICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DHHS IHS YAKAMA SERVICE UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098652102 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098652102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALVER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5098652102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YAKAMA INDIAN HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 51239 | 01 | WA | LABOR & INDUSTRY RX # | OTHER | AW3308574 | 01 | WA | DEA GRP # | OTHER | 4926311 | 01 | WA | NATL ASSN BD PHARM | OTHER | 21940 | 01 | WA | LABOR & INDUSTRY MED # | OTHER | 7100506 | 05 | WA | MEDICAID |