Provider Demographics
NPI:1598184087
Name:CHEROCREEK NATION
Entity Type:Organization
Organization Name:CHEROCREEK NATION
Other - Org Name:CHIEF OF CHEROCREEK NATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARABALLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD HC
Authorized Official - Phone:541-393-9060
Mailing Address - Street 1:831 TALENT AVE
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-9613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:831 TALENT AVE
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-9613
Practice Address - Country:US
Practice Address - Phone:541-393-9060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC002495302251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare