Provider Demographics
NPI:1073630174
Name:SOUTHERN UTE INDIAN TRIBE
Entity Type:Organization
Organization Name:SOUTHERN UTE INDIAN TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-563-4742
Mailing Address - Street 1:PHARMACY DEPT
Mailing Address - Street 2:PO BOX 899
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137
Mailing Address - Country:US
Mailing Address - Phone:970-563-4581
Mailing Address - Fax:970-563-0206
Practice Address - Street 1:123 WEEMINUCHE
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-4781
Practice Address - Fax:970-563-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67553541Medicaid
2003394OtherPK