Healthcare Provider Details

I. General information

NPI: 1346247947
Provider Name (Legal Business Name): SOUTHERN INDIAN HEALTH COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

4058 WILLOWS ROAD
ALPINE CA
91901-1668
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax: 619-659-3140
Mailing address:
  • Phone: 619-445-1188
  • Fax: 619-659-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: TERRANCE A KING
Title or Position: CFO
Credential:
Phone: 619-445-1188