Provider Demographics
NPI:1801949763
Name:SHOSHONE BANNOCK TRIBES, INC
Entity type:Organization
Organization Name:SHOSHONE BANNOCK TRIBES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-478-3744
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-238-2400
Mailing Address - Fax:208-238-5462
Practice Address - Street 1:717 MISSION ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0306
Practice Address - Country:US
Practice Address - Phone:208-238-2400
Practice Address - Fax:208-238-5462
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOSHONE BANNOCK TRIBES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-22
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002264100Medicaid
ID003399100Medicaid
ID8063500Medicaid
ID8064977Medicaid
ID806648600Medicaid
ID80662922Medicaid