Provider Demographics
NPI:1710029756
Name:EASTERN BAND OF CHEROKEE INDIANS
Entity Type:Organization
Organization Name:EASTERN BAND OF CHEROKEE INDIANS
Other - Org Name:CHEROKEE DIABETES PROGRAM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:828-497-1996
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:828-497-1996
Mailing Address - Fax:
Practice Address - Street 1:806 ACQUONI RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:CHEROKEE
Practice Address - State:NC
Practice Address - Zip Code:28719
Practice Address - Country:US
Practice Address - Phone:828-497-1996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC344572A261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC341904Medicare Oscar/Certification