Provider Demographics
NPI:1740202308
Name:NAYTAHWAUSH HEALTH STATION
Entity Type:Organization
Organization Name:NAYTAHWAUSH HEALTH STATION
Other - Org Name:WHITE EARTH HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-4300
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:NAYTAHWAUSH
Mailing Address - State:MN
Mailing Address - Zip Code:56566-0190
Mailing Address - Country:US
Mailing Address - Phone:218-935-2238
Mailing Address - Fax:218-935-5085
Practice Address - Street 1:2471 310TH AVE
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557
Practice Address - Country:US
Practice Address - Phone:218-935-2238
Practice Address - Fax:218-935-5085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE EARTH INDIAN HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-24
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHS000Medicare UPIN
HSZ053Medicare ID - Type Unspecified