=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841856986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWESTERN BAND OF THE SHOSHONE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2019
-----------------------------------------------------
Last Update Date | 03/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 984 S 500 W STE 3
-----------------------------------------------------
City | BRIGHAM CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84302-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-239-8524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 N MAIN ST
-----------------------------------------------------
City | BRIGHAM CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84302-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-734-2286
-----------------------------------------------------
Fax | 435-734-0424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF HEALTH & HUMAN SERVICES
-----------------------------------------------------
Name | HUNTER TIMBIMBOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-237-8066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------