Provider Demographics
NPI:1821159518
Name:KICKAPOO TRADITIONAL TRIBE OF TEXAS
Entity Type:Organization
Organization Name:KICKAPOO TRADITIONAL TRIBE OF TEXAS
Other - Org Name:TEXAS BAND OF KICKAPOO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIZONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-421-5903
Mailing Address - Street 1:2192 ROSITA VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-9752
Mailing Address - Country:US
Mailing Address - Phone:830-421-5349
Mailing Address - Fax:830-421-5417
Practice Address - Street 1:2192 ROSITA VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-9752
Practice Address - Country:US
Practice Address - Phone:830-421-5349
Practice Address - Fax:830-757-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHSZ222OtherMEDICARE
TX200158801Medicaid