Provider Demographics
NPI:1316449291
Name:FT. MCDERMITT PAIUTE SHOSHONE TRIBE
Entity type:Organization
Organization Name:FT. MCDERMITT PAIUTE SHOSHONE TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FERGUS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LAUGHRIDGE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:775-532-8522
Mailing Address - Street 1:P.O BOX 315
Mailing Address - Street 2:
Mailing Address - City:MCDERMITT
Mailing Address - State:NV
Mailing Address - Zip Code:89421-0315
Mailing Address - Country:US
Mailing Address - Phone:775-532-8522
Mailing Address - Fax:775-532-8024
Practice Address - Street 1:112 NORTH RESERVATION RD
Practice Address - Street 2:
Practice Address - City:MCDERMITT
Practice Address - State:NV
Practice Address - Zip Code:89421-0315
Practice Address - Country:US
Practice Address - Phone:775-532-8522
Practice Address - Fax:775-532-8024
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FT. MCDERMITT PAUITE-SHOSHONE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-06
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588710719Medicaid
NV100561450Medicaid