Provider Demographics
NPI:1114136066
Name:ROUND VALLEY INDIAN HEALTH CENTER
Entity Type:Organization
Organization Name:ROUND VALLEY INDIAN HEALTH CENTER
Other - Org Name:YUKI TRAILS HUMAN SERVICES DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTHERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-983-6404
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:COVELO
Mailing Address - State:CA
Mailing Address - Zip Code:95428-0247
Mailing Address - Country:US
Mailing Address - Phone:707-983-6404
Mailing Address - Fax:707-983-6184
Practice Address - Street 1:23000 HENDERSON LANE
Practice Address - Street 2:
Practice Address - City:COVELO
Practice Address - State:CA
Practice Address - Zip Code:95428-0247
Practice Address - Country:US
Practice Address - Phone:707-983-6404
Practice Address - Fax:707-983-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230007AN261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP11697FMedicaid
CATHP11697FMedicaid