Healthcare Provider Details

I. General information

NPI: 1093888547
Provider Name (Legal Business Name): QUINAULT INDIAN NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WA DRIVE
TAHOLAH WA
98587
US

IV. Provider business mailing address

PO BOX 219 1505 KLA-OOK-WA DR.
TAHOLAH WA
98587
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-4602
Mailing address:
  • Phone: 360-276-4405
  • Fax: 360-276-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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