Provider Demographics
NPI:1144222761
Name:DUCKWATER SHOSHONE TRIBE
Entity Type:Organization
Organization Name:DUCKWATER SHOSHONE TRIBE
Other - Org Name:DUCKWATER HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:TRIBAL MANAGER CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-863-0227
Mailing Address - Street 1:PO BOX 140087
Mailing Address - Street 2:
Mailing Address - City:DUCKWATER
Mailing Address - State:NV
Mailing Address - Zip Code:89314-0087
Mailing Address - Country:US
Mailing Address - Phone:775-863-0222
Mailing Address - Fax:775-863-0142
Practice Address - Street 1:502 DUCKWATER FALLS RD
Practice Address - Street 2:
Practice Address - City:DUCKWATER
Practice Address - State:NV
Practice Address - Zip Code:89314-0087
Practice Address - Country:US
Practice Address - Phone:775-863-0222
Practice Address - Fax:775-863-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004712001Medicaid
NV003112002OtherHEALTHY KIDS SCREENING