Provider Demographics
NPI:1780755454
Name:CONFEDERATED TRIBES OF COOS, LOWER UMPQUA & SIUSLAW INDIANS
Entity type:Organization
Organization Name:CONFEDERATED TRIBES OF COOS, LOWER UMPQUA & SIUSLAW INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:III
Authorized Official - Credentials:MHA
Authorized Official - Phone:808-214-7269
Mailing Address - Street 1:150 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-3233
Mailing Address - Country:US
Mailing Address - Phone:541-435-7200
Mailing Address - Fax:541-354-7201
Practice Address - Street 1:150 S WALL ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-3233
Practice Address - Country:US
Practice Address - Phone:541-435-7200
Practice Address - Fax:541-888-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No125J00000XDental ProvidersDental Therapist
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165383Medicaid
OR500838955Medicaid
ORRP-0003971OtherOREGON BOARD OF PHARMACY - RETAIL DRUG OUTLET
ORRP-0003971-CSOtherOREGON BOARD OF PHARMACY - CONTROLLED SUBSTANCE