Provider Demographics
NPI:1336907948
Name:MOWA BAND OF CHOCTAW INDIANS
Entity Type:Organization
Organization Name:MOWA BAND OF CHOCTAW INDIANS
Other - Org Name:MOWA CHOCTAW TRIBAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:LEBARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-786-0829
Mailing Address - Street 1:1080 RED FOX RD W
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:AL
Mailing Address - Zip Code:36560-2629
Mailing Address - Country:US
Mailing Address - Phone:251-786-0829
Mailing Address - Fax:855-933-1195
Practice Address - Street 1:1080 RED FOX RD W
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:AL
Practice Address - Zip Code:36560-2629
Practice Address - Country:US
Practice Address - Phone:251-829-9023
Practice Address - Fax:855-933-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty