Basic Information
| Provider Information | |||||||||
| NPI: | 1821280785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAKAH TRIBE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SOPHIE TRETTEVICK INDIAN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410 | ||||||||
| Address2: | 250 FORT STREET | ||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452233 | ||||||||
| FaxNumber: | 3606452305 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 FORT STREET | ||||||||
| Address2: | |||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452233 | ||||||||
| FaxNumber: | 3606452305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUCKINGHAM | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3606452233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.