MEDICARE: FORT MOJAVE INDIAN TRIBE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EAP00010F	OTHER	CA	EAPC
2	0500888779	OTHER		CLIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306897962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT MOJAVE INDIAN TRIBE

Provider Business Mailing Address
First Line	:	1607 PLANTATION RD
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86440-9686
Country	:	US
Telephone Number	:	928-346-4679
Fax Number	:	928-346-4686

Provider Business Practice Location Address
First Line	:	1607 PLANTATION RD
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86440-9686
Country	:	US
Telephone Number	:	928-346-4679
Fax Number	:	928-346-4686

Authorized Official
Title or Position	:	TRIBAL CHAIRPERSON
Name	:	MR. TIM WILLIAMS
Credential	:
Telephone Number	:	760-629-4591

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	02/06/2023

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Directions to “FORT MOJAVE INDIAN TRIBE ” Practice Location

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