Provider Demographics
NPI:1992582613
Name:PUYALLUP TRIBAL OPIOID CLINIC, INC.
Entity type:Organization
Organization Name:PUYALLUP TRIBAL OPIOID CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:KERSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-859-2742
Mailing Address - Street 1:6650 GUNPARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-7003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 EAST 26TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98421
Practice Address - Country:US
Practice Address - Phone:253-881-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-14
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder