Healthcare Provider Details

I. General information

NPI: 1083980080
Provider Name (Legal Business Name): KALISPEL TRIBE OF INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2012
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 LECLERC RD N STE 1
CUSICK WA
99119-5015
US

IV. Provider business mailing address

PO BOX 67
USK WA
99180-0067
US

V. Phone/Fax

Practice location:
  • Phone: 509-447-7111
  • Fax: 509-445-1152
Mailing address:
  • Phone: 509-447-7111
  • Fax: 509-445-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00009801
License Number StateWA

VIII. Authorized Official

Name: TRACY LYNN BIRDTAIL
Title or Position: AM
Credential:
Phone: 509-447-7112