Provider Demographics
NPI:1497870372
Name:CONFEDERATE TRIBES OF THE COLVILLE RESERVATION
Entity type:Organization
Organization Name:CONFEDERATE TRIBES OF THE COLVILLE RESERVATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-722-7006
Mailing Address - Street 1:39 SHORTCUT ROAD
Mailing Address - Street 2:PO BOX 290
Mailing Address - City:INCHELIUM
Mailing Address - State:WA
Mailing Address - Zip Code:99138-0290
Mailing Address - Country:US
Mailing Address - Phone:509-722-7006
Mailing Address - Fax:509-722-7021
Practice Address - Street 1:39 SHORTCUT ROAD
Practice Address - Street 2:
Practice Address - City:INCHELIUM
Practice Address - State:WA
Practice Address - Zip Code:99138-0290
Practice Address - Country:US
Practice Address - Phone:509-722-7006
Practice Address - Fax:509-722-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7085426Medicaid