Provider Demographics
NPI:1376592287
Name:COQUILLE INDIAN TRIBE
Entity Type:Organization
Organization Name:COQUILLE INDIAN TRIBE
Other - Org Name:KO-KWELL WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-888-9494
Mailing Address - Street 1:PO BOX 3190
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0407
Mailing Address - Country:US
Mailing Address - Phone:541-888-9494
Mailing Address - Fax:541-888-4435
Practice Address - Street 1:630 MILUK DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7728
Practice Address - Country:US
Practice Address - Phone:541-888-9494
Practice Address - Fax:541-888-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165031Medicaid
OR261Q00000XOtherTAXONOMY