Provider Demographics
NPI:1619010634
Name:EASTERN BAND OF CHEROKEE INDIANS
Entity Type:Organization
Organization Name:EASTERN BAND OF CHEROKEE INDIANS
Other - Org Name:SEE 1588795165
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH CARE BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:QUILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-359-6194
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:NC
Mailing Address - Zip Code:28719-0666
Mailing Address - Country:US
Mailing Address - Phone:828-359-6240
Mailing Address - Fax:828-497-8178
Practice Address - Street 1:73 KAISER WILNOTY DRIVE
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:NC
Practice Address - Zip Code:28719-0736
Practice Address - Country:US
Practice Address - Phone:828-359-6240
Practice Address - Fax:828-497-8178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN BAND OF CHEROKEE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC344572A261QF0400X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC341900Medicare Oscar/Certification