Basic Information
| Provider Information | |||||||||
| NPI: | 1528105541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKAMA INDIAN HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IHS YAKAMA SERVICE UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098651202 | ||||||||
| FaxNumber: | 5098654986 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098651202 | ||||||||
| FaxNumber: | 5098654986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | SAMPSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5098652102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
ID Information
| ID | Type | State | Issuer | Description | AW3308574 | 01 | WA | DEA | OTHER | 7100506 | 05 | WA | MEDICAID |