Basic Information
| Provider Information | |||||||||
| NPI: | 1528285038 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COWLITZ INDIAN TRIBE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COWLITZ TRIBAL TREATMENT | ||||||||
| 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: | 900 FIR ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605758275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | SHAVON | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3603539431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COWLITZ INDIAN TRIBE | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 1994987 | 05 | WA | MEDICAID |