Basic Information
| Provider Information | |||||||||
| NPI: | 1386726032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KARUK TRIBE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KARUK ORLEANS MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1016 | ||||||||
| Address2: | |||||||||
| City: | HAPPY CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960391016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304931600 | ||||||||
| FaxNumber: | 5304931648 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 ASIP RD | ||||||||
| Address2: | |||||||||
| City: | ORLEANS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955560249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306273452 | ||||||||
| FaxNumber: | 5036273445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATTEBERY | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TRIBAL CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 5304931600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1386726032 | 01 | CA | MEDICARE | OTHER | 1386726032 | 05 | CA | MEDICAID | ZZZ09862Z | 01 | BLUE SHIELD OF CALIFORNIA | OTHER |