Basic Information
Provider Information
NPI: 1619194123
EntityType: 2
ReplacementNPI:  
OrganizationName: COWLITZ INDIAN TRIBE
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: COWLITZ INDIAN TRIBAL HEALTH SERVICES
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2429
Address2:  
City: LONGVIEW
State: WA
PostalCode: 986328486
CountryCode: US
TelephoneNumber: 3605758275
FaxNumber: 3605751950
Practice Location
Address1: 922 FIR ST
Address2:  
City: LONGVIEW
State: WA
PostalCode: 98632
CountryCode: US
TelephoneNumber: 3605758275
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/19/2007
LastUpdateDate: 07/16/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KELLER
AuthorizedOfficialFirstName: SHAVON
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: BILLING SUPERVISOR
AuthorizedOfficialTelephone: 3603539431
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: COWLITZ INDIAN TRIBE
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QH0100X  N Ambulatory Health Care FacilitiesClinic/CenterHealth Service
2083P0901X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine

ID Information
IDTypeStateIssuerDescription
198122405WA MEDICAID


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