Healthcare Provider Details

I. General information

NPI: 1427171628
Provider Name (Legal Business Name): ROGER SAUX HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLAOOKWA DRIVE
TAHOLAH WA
98587
US

IV. Provider business mailing address

1505 KLA-OOK-WAH 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 Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License NumberFEDERAL
License Number StateWA

VIII. Authorized Official

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