Healthcare Provider Details

I. General information

NPI: 1871182683
Provider Name (Legal Business Name): FORT MCDERMITT PAIUTE SHOSHONE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N RESERVATION RD
FT MCDERMITT NV
89421-9804
US

IV. Provider business mailing address

PO BOX 315
FT MCDERMITT NV
89421-0315
US

V. Phone/Fax

Practice location:
  • Phone: 775-532-8522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. FERGUS JOHN LAUGHRIDGE
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 208-250-8665