Provider Demographics
NPI:1467811562
Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNCIL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-898-4814
Mailing Address - Street 1:HC 61 BOX 6104
Mailing Address - Street 2:
Mailing Address - City:IBAPAH
Mailing Address - State:UT
Mailing Address - Zip Code:84034-6003
Mailing Address - Country:US
Mailing Address - Phone:435-234-1138
Mailing Address - Fax:435-234-1162
Practice Address - Street 1:660 S 200 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3835
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:801-364-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8547079-17043336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy