Provider Demographics
NPI:1497700801
Name:RENO SPARKS INDIAN COLONY
Entity Type:Organization
Organization Name:RENO SPARKS INDIAN COLONY
Other - Org Name:RENO SPARKS TRIBAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-329-5162
Mailing Address - Street 1:1715 KUENZLI STREET
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1117
Mailing Address - Country:US
Mailing Address - Phone:775-329-5162
Mailing Address - Fax:775-334-4350
Practice Address - Street 1:1715 KUENZLI STREET
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1117
Practice Address - Country:US
Practice Address - Phone:775-329-5162
Practice Address - Fax:775-334-4350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENO SPARKS INDIAN COLONY DBA RENO SPARKS TRIBAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
NV261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004716904Medicaid
NV003116904Medicaid
NV004716904Medicaid