Provider Demographics
NPI:1649061029
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:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL ADMINSITRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-445-1147
Mailing Address - Street 1:1821 LECLERC RD N STE 1
Mailing Address - Street 2:
Mailing Address - City:CUSICK
Mailing Address - State:WA
Mailing Address - Zip Code:99119-5015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1821 LECLERC RD N STE 1
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-5015
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:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy