Provider Demographics
NPI:1326889023
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:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:III
Authorized Official - Credentials:MHA
Authorized Official - Phone:808-214-7269
Mailing Address - Street 1:1245 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2895
Mailing Address - Country:US
Mailing Address - Phone:541-888-6433
Mailing Address - Fax:
Practice Address - Street 1:1245 FULTON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2895
Practice Address - Country:US
Practice Address - Phone:541-888-6433
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
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165383Medicaid