Provider Demographics
NPI:1861722258
Name:COWLITZ INDIAN TRIBE
Entity type:Organization
Organization Name:COWLITZ INDIAN TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-353-9431
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9431
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:107 SPENCER RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:WA
Practice Address - Zip Code:98591
Practice Address - Country:US
Practice Address - Phone:360-353-9431
Practice Address - Fax:360-353-9440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COWLITZ INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-06
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service