Provider Demographics
NPI:1518425511
Name:QUILEUTE TRIBAL COUNCIL
Entity type:Organization
Organization Name:QUILEUTE TRIBAL COUNCIL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENCY
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-867-0709
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:LA PUSH
Mailing Address - State:WA
Mailing Address - Zip Code:98350-0189
Mailing Address - Country:US
Mailing Address - Phone:360-374-3358
Mailing Address - Fax:360-374-2644
Practice Address - Street 1:560 QUILEUTE HEIGHTS LOOP
Practice Address - Street 2:
Practice Address - City:LA PUSH
Practice Address - State:WA
Practice Address - Zip Code:98350
Practice Address - Country:US
Practice Address - Phone:360-374-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUILEUTE TRIBAL COUNCIL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-08
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty