Provider Demographics
NPI:1801348024
Name:FORT MCDERMITT WELLNESS CENTER
Entity type:Organization
Organization Name:FORT MCDERMITT WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-532-8259
Mailing Address - Street 1:112 NO RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:MCDERMITT
Mailing Address - State:NV
Mailing Address - Zip Code:89421-0315
Mailing Address - Country:US
Mailing Address - Phone:775-532-8522
Mailing Address - Fax:775-532-8024
Practice Address - Street 1:112 NO RESERVATION RD
Practice Address - Street 2:
Practice Address - City:MCDERMITT
Practice Address - State:NV
Practice Address - Zip Code:89421-0315
Practice Address - Country:US
Practice Address - Phone:775-532-8522
Practice Address - Fax:775-532-8024
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT MCDERMITT PAIUTE SHOSHONE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002392261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053394866OtherNPI
CA1104037704OtherNPI
NV1518416577OtherNPI
NV1386917011OtherNPI
NV1043338593OtherNPI