Basic Information
| Provider Information | |||||||||
| NPI: | 1508110370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YAKAMA NATION CCAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 151 | ||||||||
| Address2: | 20 GUNNYON ROAD | ||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098654333 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 GUNNYON RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098654333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2012 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHIRLEY | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN. ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5098655121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | CP 00001456 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | CP 00001456 | 05 | WA | MEDICAID |