Provider Demographics
NPI:1700027927
Name:CONFEDERATED TRIBES OF THE WARM SPRINGS RESERVATION OF OREGON
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE WARM SPRINGS RESERVATION OF OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER-CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:STACONA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:541-553-3232
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-3001
Mailing Address - Country:US
Mailing Address - Phone:541-553-3205
Mailing Address - Fax:541-553-4900
Practice Address - Street 1:1115 WASCO STREET
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-3001
Practice Address - Country:US
Practice Address - Phone:541-553-3205
Practice Address - Fax:541-553-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164964Medicaid