Healthcare Provider Details

I. General information

NPI: 1487905691
Provider Name (Legal Business Name): INDIAN HEALTH SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 GALENA ST SE
LACEY WA
98503-2187
US

IV. Provider business mailing address

4109 GALENA ST SE
LACEY WA
98503-2187
US

V. Phone/Fax

Practice location:
  • Phone: 210-789-4047
  • Fax: 307-332-0131
Mailing address:
  • Phone: 210-789-4047
  • Fax: 307-332-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number55352
License Number StateTX

VIII. Authorized Official

Name: LILLIAN OCHOA
Title or Position: LAB TECH
Credential: MLT
Phone: 210-789-4047