Basic Information
| Provider Information | |||||||||
| NPI: | 1710029756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN BAND OF CHEROKEE INDIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CHEROKEE DIABETES PROGRAM | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 666 | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287190666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284971996 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 806 ACQUONI RD. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284971996 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADLEY | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8284971996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 344572A | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.