Provider Demographics
NPI:1750510277
Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-359-2256
Mailing Address - Street 1:660 S 200 E STE 250
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3846
Mailing Address - Country:US
Mailing Address - Phone:801-359-2256
Mailing Address - Fax:801-364-4392
Practice Address - Street 1:195 TRIBAL CENTER RD
Practice Address - Street 2:
Practice Address - City:IBAPAH
Practice Address - State:UT
Practice Address - Zip Code:84034
Practice Address - Country:US
Practice Address - Phone:435-234-1194
Practice Address - Fax:435-234-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty