Basic Information
| Provider Information | |||||||||
| NPI: | 1639470073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YAKAMA NATION COMPREHENSIVE COMMUNITY ALCOHOLISM PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 523 | ||||||||
| Address2: | 20 GUNNYON RD. | ||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 GUNNYON RD. | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5098655121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | CO 60181087 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | CO 60181087 | 01 | WA | WASHINGTON STATE DEPARTMENT OF HEALTH | OTHER |