Healthcare Provider Details

I. General information

NPI: 1225414519
Provider Name (Legal Business Name): SHOSHONE BANNOCK TRIBES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAJO DRIVE BLDG 70
FORT HALL ID
83203-0306
US

IV. Provider business mailing address

PO BOX 306
FORT HALL ID
83203-0306
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-3995
  • Fax: 208-478-4040
Mailing address:
  • Phone: 208-478-3995
  • Fax: 208-478-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MELISSA M JOHNSON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 517-896-3464