Provider Demographics
NPI:1669594057
Name:KOOTENAI TRIBE OF IDAHO
Entity type:Organization
Organization Name:KOOTENAI TRIBE OF IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-267-5223
Mailing Address - Street 1:PO BOX T
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1279
Mailing Address - Country:US
Mailing Address - Phone:208-267-5223
Mailing Address - Fax:208-267-8419
Practice Address - Street 1:100 CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-1279
Practice Address - Country:US
Practice Address - Phone:208-267-5223
Practice Address - Fax:208-267-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDG007100Medicaid
IDDC786OtherBLUE CROSS
IDDC786OtherHMO
IDDC786OtherBLUE CROSS
IDG007100Medicaid