Basic Information
| Provider Information | |||||||||
| NPI: | 1699119123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIAN HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098655374 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098655374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2013 | ||||||||
| LastUpdateDate: | 04/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOSEY | ||||||||
| AuthorizedOfficialFirstName: | CAROLYNN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 5098652102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | RN60065570 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.