Basic Information
Provider Information | |||||||||
NPI: | 1730227810 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YAKAMA INDIAN HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DHHS IHS YAKAMA SERVICE UNIT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 BUSTER RD | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989489792 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098652102 | ||||||||
FaxNumber: | 5098654986 | ||||||||
Practice Location | |||||||||
Address1: | 401 BUSTER RD | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989489792 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098652102 | ||||||||
FaxNumber: | 5098654986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 10/22/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALVER | ||||||||
AuthorizedOfficialFirstName: | DAWN | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5098652102 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | YAKAMA INDIAN HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | R.N. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 21940 | 01 | WA | LABOR & INDUSTRY MED # | OTHER | 7100506 | 05 | WA |   | MEDICAID | 51239 | 01 | WA | LABOR & INDUSTRY RX # | OTHER | AW3308574 | 01 | WA | DEA GRP # | OTHER | 4926311 | 01 | WA | NATL ASSN BD PHARM | OTHER |