=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902865637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YAKAMA INDIAN HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 BUSTER RD
-----------------------------------------------------
City | TOPPENISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98948-9792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-865-2102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 BUSTER RD
-----------------------------------------------------
City | TOPPENISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98948-9792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DONN KRUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-865-2102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 5190415-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------