Healthcare Provider Details

I. General information

NPI: 1629078274
Provider Name (Legal Business Name): KLAMATH TRIBAL HEALTH & FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CHILOQUIN BLVD
CHILOQUIN OR
97624
US

IV. Provider business mailing address

3949 SOUTH 6TH STREET
KLAMATH FALLS OR
97603-4746
US

V. Phone/Fax

Practice location:
  • Phone: 541-783-2438
  • Fax: 541-783-3273
Mailing address:
  • Phone: 541-882-1487
  • Fax: 541-882-8277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: NIKOWA NICOLE MENDEZ
Title or Position: COMPLIANCE ADMINISTRATOR
Credential: MHA, BSN, RN, THRP
Phone: 541-882-1487