Healthcare Provider Details

I. General information

NPI: 1790824530
Provider Name (Legal Business Name): SHOSHONE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SHIPTON LANE
FORT WASHAKIE WY
82514
US

IV. Provider business mailing address

PO BOX 998
FORT WASHAKIE WY
82514-0998
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2998
  • Fax: 307-332-4955
Mailing address:
  • Phone: 307-332-2998
  • Fax: 307-332-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number07-177
License Number StateWY

VIII. Authorized Official

Name: MS. DIANE GARCIA
Title or Position: CEO, NURSE MANAGER
Credential: RN, BSN, CNN
Phone: 307-332-2998