Healthcare Provider Details

I. General information

NPI: 1568682847
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 COLVILLE STREET
NESPELEM WA
99155-0150
US

IV. Provider business mailing address

21 COLVILLE STREET
NESPELEM WA
99155-0150
US

V. Phone/Fax

Practice location:
  • Phone: 509-634-2783
  • Fax: 509-634-2781
Mailing address:
  • Phone: 509-634-2783
  • Fax: 509-634-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number7119928
License Number StateWA

VIII. Authorized Official

Name: MRS. AMY CHURCH
Title or Position: REVENUE CYCLE MANAGER
Credential: CRCR
Phone: 509-634-2783