Healthcare Provider Details

I. General information

NPI: 1902240070
Provider Name (Legal Business Name): EASTERN SHOSHONE TRIBAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 US HWY 287
FORT WASHAKIE WY
82514-0250
US

IV. Provider business mailing address

PO BOX 250
FORT WASHAKIE WY
82514-0250
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-6805
  • Fax: 307-332-0458
Mailing address:
  • Phone: 307-332-6805
  • Fax: 307-332-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID MEYERS
Title or Position: DIRECTOR
Credential: BS
Phone: 307-332-6805