=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265588537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAUK-SUIATTLE INDIAN TRIBE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5318 CHIEF BROWN LN
-----------------------------------------------------
City | DARRINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98241-9420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-436-1400
-----------------------------------------------------
Fax | 360-436-0242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5318 CHIEF BROWN LN
-----------------------------------------------------
City | DARRINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98241-9420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH & SOCIAL SERVICES DIRECTOR
-----------------------------------------------------
Name | RYAN KIPPES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-436-0131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------