Provider Demographics
NPI:1770564049
Name:SUSANVILLE INDIAN RANCHERIA
Entity type:Organization
Organization Name:SUSANVILLE INDIAN RANCHERIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOVEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-257-6264
Mailing Address - Street 1:795 JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3628
Mailing Address - Country:US
Mailing Address - Phone:530-257-2542
Mailing Address - Fax:530-251-5208
Practice Address - Street 1:795 JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3628
Practice Address - Country:US
Practice Address - Phone:530-257-2542
Practice Address - Fax:530-251-5208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000120261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA470460Medicaid
CATHP03876FMedicaid
CAPHA470460Medicaid
CA05-1904Medicare ID - Type UnspecifiedMEDI/CARE PROV. NUMBER