Provider Demographics
NPI:1699967265
Name:NOOKSACK INDIAN TRIBE
Entity type:Organization
Organization Name:NOOKSACK INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH & SOCIAL SERVICE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-592-5176
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0157
Mailing Address - Country:US
Mailing Address - Phone:360-592-5176
Mailing Address - Fax:
Practice Address - Street 1:6760 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-306-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOOKSACK INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5400023Medicare PIN