Healthcare Provider Details

I. General information

NPI: 1922320910
Provider Name (Legal Business Name): PHS INDIAN HEALTH SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL DRIVE
FORT WASHAKIE WY
82514-0128
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: 307-332-5753
Mailing address:
  • Phone: 307-332-7300
  • Fax: 307-332-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number19751
License Number StateWY

VIII. Authorized Official

Name: MRS. TARA ROBINSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 307-335-5964