Healthcare Provider Details

I. General information

NPI: 1164649679
Provider Name (Legal Business Name): COWLITZ INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 NE 26TH AVE
VANCOUVER WA
98665-0672
US

IV. Provider business mailing address

P.O. BOX 2429
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8228
  • Fax: 360-575-1950
Mailing address:
  • Phone: 360-397-8228
  • Fax: 360-575-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

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