Provider Demographics
NPI:1306897962
Name:FORT MOJAVE INDIAN TRIBE
Entity type:Organization
Organization Name:FORT MOJAVE INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRPERSON
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-629-4591
Mailing Address - Street 1:1607 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-9686
Mailing Address - Country:US
Mailing Address - Phone:928-346-4679
Mailing Address - Fax:928-346-4686
Practice Address - Street 1:1607 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440-9686
Practice Address - Country:US
Practice Address - Phone:928-346-4679
Practice Address - Fax:928-346-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP00010FOtherEAPC
0500888779OtherCLIA
AZ890211Medicaid
AZ890211Medicaid