Provider Demographics
NPI:1619377942
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other - Org Name:SHERMAN INDIAN SCHOOL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-263-1674
Mailing Address - Street 1:PO BOX 95460
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:602-581-6088
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:9010 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4431
Practice Address - Country:US
Practice Address - Phone:951-509-8914
Practice Address - Fax:602-200-5383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX INDIAN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-22
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health