Provider Demographics
NPI:1003251638
Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-359-2256
Mailing Address - Street 1:660 S 200 E
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3835
Mailing Address - Country:US
Mailing Address - Phone:801-359-2256
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3846
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8547079-1704332800000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140406OtherPK