Provider Demographics
NPI:1093931107
Name:FORT BIDWELL INDIAN COMMUNITY
Entity Type:Organization
Organization Name:FORT BIDWELL INDIAN COMMUNITY
Other - Org Name:WARNER MOUNTAIN INDIAN HEALTH PROJECT
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:530-279-6194
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:FORT BIDWELL
Mailing Address - State:CA
Mailing Address - Zip Code:96112-0247
Mailing Address - Country:US
Mailing Address - Phone:530-279-6194
Mailing Address - Fax:530-279-6288
Practice Address - Street 1:132 MEE THEE UH ROAD
Practice Address - Street 2:
Practice Address - City:FORT BIDWELL
Practice Address - State:CA
Practice Address - Zip Code:96112
Practice Address - Country:US
Practice Address - Phone:530-279-6194
Practice Address - Fax:530-279-6288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP70973FMedicaid
CAO5D0692143OtherCLIA
CAZZZ270012ZMedicare ID - Type UnspecifiedMEDICARE