Provider Demographics
NPI:1528230224
Name:SHOSHONE-PAIUTE TRIBES
Entity type:Organization
Organization Name:SHOSHONE-PAIUTE TRIBES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-757-2415
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:OWYHEE
Mailing Address - State:NV
Mailing Address - Zip Code:89832-0130
Mailing Address - Country:US
Mailing Address - Phone:775-757-2415
Mailing Address - Fax:775-757-3010
Practice Address - Street 1:1623 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:OWYHEE
Practice Address - State:NV
Practice Address - Zip Code:89832-1200
Practice Address - Country:US
Practice Address - Phone:775-757-2415
Practice Address - Fax:757-572-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVN/A261Q00000X
NV261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804128900Medicaid
NV005204909Medicaid
ID804128900Medicaid