Healthcare Provider Details

I. General information

NPI: 1306897962
Provider Name (Legal Business Name): FORT MOJAVE INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 PLANTATION RD
MOHAVE VALLEY AZ
86440-9686
US

IV. Provider business mailing address

1607 PLANTATION RD
MOHAVE VALLEY AZ
86440-9686
US

V. Phone/Fax

Practice location:
  • Phone: 928-346-4679
  • Fax: 928-346-4686
Mailing address:
  • Phone: 928-346-4679
  • Fax: 928-346-4686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM WILLIAMS
Title or Position: TRIBAL CHAIRPERSON
Credential:
Phone: 760-629-4591