Provider Demographics
NPI:1275762254
Name:PAIUTE INDIAN TRIBE OF UTAH
Entity Type:Organization
Organization Name:PAIUTE INDIAN TRIBE OF UTAH
Other - Org Name:KANOSH MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DEPARTMENT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CRANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:435-586-1112
Mailing Address - Street 1:440 N PAIUTE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-6181
Mailing Address - Country:US
Mailing Address - Phone:435-568-1112
Mailing Address - Fax:435-867-1514
Practice Address - Street 1:157 N PAIUTE DR RESERVATION RD.
Practice Address - Street 2:
Practice Address - City:KANOSH
Practice Address - State:UT
Practice Address - Zip Code:84637
Practice Address - Country:US
Practice Address - Phone:435-759-2610
Practice Address - Fax:435-867-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
6254530001Medicare NSC