Provider Demographics
NPI:1417084708
Name:WARM SPRINGS HEALTH AND WELLNESS DHHS IHS WARM SPRINGS SERVICE UNIT
Entity Type:Organization
Organization Name:WARM SPRINGS HEALTH AND WELLNESS DHHS IHS WARM SPRINGS SERVICE UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-553-1196
Mailing Address - Street 1:1270 KOT NUM RD
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2135
Practice Address - Street 1:1270 KOT NUM RD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273855Medicaid
HSZ204Medicare ID - Type Unspecified