Provider Demographics
NPI:1790824530
Name:SHOSHONE TRIBE
Entity Type:Organization
Organization Name:SHOSHONE TRIBE
Other - Org Name:WIND RIVER DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, NURSE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, CNN
Authorized Official - Phone:307-332-2998
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0998
Mailing Address - Country:US
Mailing Address - Phone:307-332-2998
Mailing Address - Fax:307-332-4955
Practice Address - Street 1:11 SHIPTON LANE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-2998
Practice Address - Fax:307-332-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07-177261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA532503Medicare ID - Type UnspecifiedMEDICARE ID NUMBER