Provider Demographics
NPI:1164649679
Name:COWLITZ INDIAN TRIBE
Entity Type:Organization
Organization Name:COWLITZ INDIAN TRIBE
Other - Org Name:COWLITZ TRIBAL TREATMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-353-9431
Mailing Address - Street 1:P.O. BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-397-8228
Mailing Address - Fax:360-575-1950
Practice Address - Street 1:7700 NE 26TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0672
Practice Address - Country:US
Practice Address - Phone:360-397-8228
Practice Address - Fax:360-575-1950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COWLITZ INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1995307Medicaid