Basic Information
| Provider Information | |||||||||
| NPI: | 1629078274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLAMATH TRIBAL HEALTH & FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3949 SOUTH 6TH STREET | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976034746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418828277 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 CHILOQUIN BLVD | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417832438 | ||||||||
| FaxNumber: | 5417833273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | POWLESS | ||||||||
| AuthorizedOfficialFirstName: | GUY | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM HEALTH GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5418821487 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 129861 | 05 | OR | MEDICAID |