Provider Demographics
NPI:1750456307
Name:SAN CARLOS APACHE TRIBE
Entity Type:Organization
Organization Name:SAN CARLOS APACHE TRIBE
Other - Org Name:WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDSLER
Authorized Official - Middle Name:A
Authorized Official - Last Name:NOSIE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:928-475-2361
Mailing Address - Street 1:PO BOX 0
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-9999
Mailing Address - Country:US
Mailing Address - Phone:928-475-4875
Mailing Address - Fax:928-475-4880
Practice Address - Street 1:#5 SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-9999
Practice Address - Country:US
Practice Address - Phone:928-475-4875
Practice Address - Fax:928-475-4880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN CARLOS APACHE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004505251S00000X
AZ251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ624230Medicaid