Healthcare Provider Details

I. General information

NPI: 1619194123
Provider Name (Legal Business Name): COWLITZ INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FIR ST
LONGVIEW WA
98632-2544
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

Practice location:
  • Phone: 360-353-9422
  • Fax:
Mailing address:
  • Phone: 360-575-8275
  • Fax: 360-575-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAVON KELLER
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 360-353-9431