Basic Information
| Provider Information | |||||||||
| NPI: | 1760651129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | K'IMA: W MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOOPA HEALTH ASSOCIATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 AIRPORT ROAD | ||||||||
| Address2: | PO BOX 1288 | ||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 AIRPORTROAD | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2008 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOARE | ||||||||
| AuthorizedOfficialFirstName: | MIHAIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5306254261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | K'IMA:W MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | EXEMPT INDIAN TRIBE | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | EAP11573F | 05 | CA | MEDICAID |