MEDICARE: BLUE LAKE RANCHERIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251K00000X	Public Health or Welfare Agency
3	261QF0050X	Non-Surgical Family Planning Clinic/Center
4	261QC1500X	Community Health Clinic/Center
5	261QM0850X	Adult Mental Health Clinic/Center
6	332U00000X	Home Delivered Meals
7	385H00000X	Respite Care
8	174200000X	Meals Provider
9	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1952120354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE LAKE RANCHERIA

Provider Business Mailing Address
First Line	:	PO BOX 428
Second Line	:
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-0428
Country	:	US
Telephone Number	:	707-668-7226
Fax Number	:

Provider Business Practice Location Address
First Line	:	428 CHARTIN RD
Second Line	:
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-9722
Country	:	US
Telephone Number	:	707-668-5101
Fax Number	:	707-668-7226

Authorized Official
Title or Position	:	TRIBAL ADMINSTRATOR
Name	:	DR. JASON RAMOS
Credential	:	DC
Telephone Number	:	707-668-7226

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	10/03/2024

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Directions to “BLUE LAKE RANCHERIA ” Practice Location

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