Healthcare Provider Details

I. General information

NPI: 1326206616
Provider Name (Legal Business Name): WIND RIVER SERVICE UNIT IHS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL DR
FORT WASHAKIE WY
82514-0000
US

IV. Provider business mailing address

PO BOX 128
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7300
  • Fax: 307-332-9446
Mailing address:
  • Phone: 307-332-7300
  • Fax: 307-332-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number9336
License Number StateWY

VIII. Authorized Official

Name: MRS. TRINA RENE' NATION
Title or Position: NURSE SPECIALIST
Credential: RN
Phone: 307-332-7300