Provider Demographics
NPI:1396937769
Name:KALISPEL INDIAN COMMUNITY OF THE KALISPEL RESERVATION WASHINGTON
Entity type:Organization
Organization Name:KALISPEL INDIAN COMMUNITY OF THE KALISPEL RESERVATION WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MEDICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSTING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-447-7111
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:CUSICK
Mailing Address - State:WA
Mailing Address - Zip Code:99119-0067
Mailing Address - Country:US
Mailing Address - Phone:509-447-7111
Mailing Address - Fax:
Practice Address - Street 1:1821 LECLERC RD N
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-9682
Practice Address - Country:US
Practice Address - Phone:509-447-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty