Healthcare Provider Details

I. General information

NPI: 1326889023
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF COOS, LOWER UMPQUA, & SIUSLAW INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 FULTON AVE
COOS BAY OR
97420-2895
US

IV. Provider business mailing address

1245 FULTON AVE
COOS BAY OR
97420-2895
US

V. Phone/Fax

Practice location:
  • Phone: 541-888-6433
  • Fax:
Mailing address:
  • Phone: 541-888-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN R REEVES III
Title or Position: HEALTH ADMINISTRATOR
Credential: MHA
Phone: 808-214-7269