Provider Demographics
NPI:1790795888
Name:NEZ PERCE TRIBAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NEZ PERCE TRIBAL HEALTH AUTHORITY
Other - Org Name:(DBA) NIMIIPUU HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:R.
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:HARTWIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-843-2271
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-0367
Mailing Address - Country:US
Mailing Address - Phone:208-843-2271
Mailing Address - Fax:208-621-4995
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:NIMIIPUU HEALTH
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540-0367
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:208-621-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QF0400X
332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805010102Medicaid
ID805010100Medicaid
ID805010100Medicaid
ID805010102Medicaid
ID6044930001Medicare NSC