Healthcare Provider Details

I. General information

NPI: 1093679862
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11665 WA HWY 21
KELLER WA
99140-7300
US

IV. Provider business mailing address

PO BOX 150
NESPELEM WA
99155-0150
US

V. Phone/Fax

Practice location:
  • Phone: 509-634-7389
  • Fax:
Mailing address:
  • Phone: 509-634-2783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AMY CHURCH
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 509-634-2783