Provider Demographics
NPI:1508296310
Name:CONFEDERATED TRIBES OF THE GOSHUTE INDIAN RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GOSHUTE INDIAN RESERVATION
Other - Org Name:GOSHUTE HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING HEALTH DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-234-1138
Mailing Address - Street 1:P.O. BOX 6104
Mailing Address - Street 2:195 TRIBAL CENTER RD
Mailing Address - City:IBAPAH
Mailing Address - State:UT
Mailing Address - Zip Code:84034-6104
Mailing Address - Country:US
Mailing Address - Phone:435-234-1138
Mailing Address - Fax:435-234-1202
Practice Address - Street 1:195 TRIBAL CENTER RD
Practice Address - Street 2:
Practice Address - City:IBAPAH
Practice Address - State:UT
Practice Address - Zip Code:84034
Practice Address - Country:US
Practice Address - Phone:435-234-1138
Practice Address - Fax:435-234-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1750510277Medicaid