Provider Demographics
NPI:1144910753
Name:CHEMEHUEVI INDIAN TRIBE
Entity type:Organization
Organization Name:CHEMEHUEVI INDIAN TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:LODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-858-4219
Mailing Address - Street 1:PO BOX 1976
Mailing Address - Street 2:
Mailing Address - City:HAVASU LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92363-1976
Mailing Address - Country:US
Mailing Address - Phone:760-858-4219
Mailing Address - Fax:
Practice Address - Street 1:1970 PALO VERDE DRIVE
Practice Address - Street 2:
Practice Address - City:HAVASU LAKE
Practice Address - State:CA
Practice Address - Zip Code:92363-1976
Practice Address - Country:US
Practice Address - Phone:760-858-5426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center