Provider Demographics
NPI:1063502714
Name:COW CREEK BAND OF UMPQUA TRIBE OF INDIANS
Entity Type:Organization
Organization Name:COW CREEK BAND OF UMPQUA TRIBE OF INDIANS
Other - Org Name:COW CREEK HEALTH & WELLNESS CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:STANPHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-672-8533
Mailing Address - Street 1:2371 NE STEPHENS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1399
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:541-677-9870
Practice Address - Street 1:2589 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6220
Practice Address - Country:US
Practice Address - Phone:541-672-8533
Practice Address - Fax:855-670-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500745176Medicaid