Provider Demographics
NPI:1316788037
Name:CONFEDERATED TRIBES OF COOS, LOWER UMPQUA & SIUSLAW INDIANS
Entity type:Organization
Organization Name:CONFEDERATED TRIBES OF COOS, LOWER UMPQUA & SIUSLAW INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:III
Authorized Official - Credentials:MHA
Authorized Official - Phone:808-214-7269
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-0076
Mailing Address - Country:US
Mailing Address - Phone:541-997-6685
Mailing Address - Fax:541-997-1715
Practice Address - Street 1:3757 HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8993
Practice Address - Country:US
Practice Address - Phone:541-997-6685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165383Medicaid