Healthcare Provider Details

I. General information

NPI: 1346465101
Provider Name (Legal Business Name): COWLITZ INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 11TH AVE
LONGVIEW WA
98632-2506
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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