Provider Demographics
NPI:1346247947
Name:SOUTHERN INDIAN HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:SOUTHERN INDIAN HEALTH COUNCIL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-445-1188
Mailing Address - Street 1:4058 WILLOWS ROAD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1668
Mailing Address - Country:US
Mailing Address - Phone:619-445-1188
Mailing Address - Fax:619-659-3138
Practice Address - Street 1:4058 WILLOWS RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1668
Practice Address - Country:US
Practice Address - Phone:619-445-1188
Practice Address - Fax:619-659-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ58086ZOtherBLUE SHIELD OF CALIFORNIA
CATHP70010FMedicaid
CAHAP70010FOtherFAMILY PACT
CAW7576AOtherMEDICARE
CAW7576AOtherMEDICARE