Healthcare Provider Details

I. General information

NPI: 1790810661
Provider Name (Legal Business Name): SHOSHONE BANNOCK TRIBES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WIDOWVILLE ROAD
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: 208-478-3786
  • Fax: 208-478-3788
Mailing address:
  • Phone: 208-478-3786
  • Fax: 208-478-3788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number2626
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: MR. VAL NAVO
Title or Position: FIRE CHIEF
Credential:
Phone: 208-478-3784