Provider Demographics
NPI:1922320910
Name:PHS INDIAN HEALTH SERVICE
Entity Type:Organization
Organization Name:PHS INDIAN HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-335-5964
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0128
Mailing Address - Country:US
Mailing Address - Phone:307-332-7300
Mailing Address - Fax:307-332-5753
Practice Address - Street 1:29 BLACK COAL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0128
Practice Address - Country:US
Practice Address - Phone:307-332-7300
Practice Address - Fax:307-332-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19751261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal