Healthcare Provider Details

I. General information

NPI: 1457542847
Provider Name (Legal Business Name): QUINAULT INDIAN NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WA DR
TAHOLAH WA
98587
US

IV. Provider business mailing address

1505 KLA-OOK-WA DR
TAHOLAH WA
98587
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-4474
Mailing address:
  • Phone: 360-276-4405
  • Fax: 360-276-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberFEDERAL FACILITY
License Number State

VIII. Authorized Official

Name: MISS MARIAH YVONNE RALSTON
Title or Position: BILLING MANAGER
Credential:
Phone: 360-276-4405