Provider Demographics
NPI:1003150814
Name:INDIAN FAMILY HEALTH CLINIC
Entity Type:Organization
Organization Name:INDIAN FAMILY HEALTH CLINIC
Other - Org Name:INDIAN FAMILY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLD COYOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-665-5569
Mailing Address - Street 1:1220 CENTRAL AVE
Mailing Address - Street 2:STE. 1B
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3764
Mailing Address - Country:US
Mailing Address - Phone:406-268-1587
Mailing Address - Fax:
Practice Address - Street 1:1220 CENTRAL AVE
Practice Address - Street 2:STE. 1B
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3764
Practice Address - Country:US
Practice Address - Phone:406-268-1587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1121261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7128836Medicaid