Provider Demographics
NPI:1003008558
Name:NISQUALLY TRIBE
Entity Type:Organization
Organization Name:NISQUALLY TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-459-5312
Mailing Address - Street 1:4816 SHE NAH NUM DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-9105
Mailing Address - Country:US
Mailing Address - Phone:360-459-5312
Mailing Address - Fax:360-407-0860
Practice Address - Street 1:4816 SHE NAH NUM DR SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-9105
Practice Address - Country:US
Practice Address - Phone:360-459-5312
Practice Address - Fax:360-407-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5400080Medicaid