Provider Demographics
NPI:1003028952
Name:SHOALWATER BAY INDIAN TRIBE
Entity Type:Organization
Organization Name:SHOALWATER BAY INDIAN TRIBE
Other - Org Name:SHOALWATER BAY TRIBAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-267-6766
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:TOKELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98590-0500
Mailing Address - Country:US
Mailing Address - Phone:360-267-0119
Mailing Address - Fax:360-267-0417
Practice Address - Street 1:2373 OLD TOKELAND RD
Practice Address - Street 2:
Practice Address - City:TOKELAND
Practice Address - State:WA
Practice Address - Zip Code:98590
Practice Address - Country:US
Practice Address - Phone:360-267-8103
Practice Address - Fax:360-267-1437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental