Healthcare Provider Details

I. General information

NPI: 1144222761
Provider Name (Legal Business Name): DUCKWATER SHOSHONE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 DUCKWATER FALLS RD
DUCKWATER NV
89314-0087
US

IV. Provider business mailing address

PO BOX 140087
DUCKWATER NV
89314-0087
US

V. Phone/Fax

Practice location:
  • Phone: 775-863-0222
  • Fax: 775-863-0142
Mailing address:
  • Phone: 775-863-0222
  • Fax: 775-863-0142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: MR. JERRY MILLETT
Title or Position: TRIBAL MANAGER CHAIRMAN
Credential:
Phone: 775-863-0227