Healthcare Provider Details

I. General information

NPI: 1407883309
Provider Name (Legal Business Name): SOUTHERN UTE INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WEEMINUCHE AVE.
IGNACIO CO
81137-0899
US

IV. Provider business mailing address

PO BOX 899
IGNACIO CO
81137-0899
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-4581
  • Fax: 970-563-0208
Mailing address:
  • Phone: 970-563-4581
  • Fax: 970-563-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: GEORGETTE C MILLER
Title or Position: SUPPORT SERVICE MANAGER
Credential: MHA, CHPSE
Phone: 970-563-2459