Provider Demographics
NPI:1952158982
Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:SORENSEN
Authorized Official - Last Name:MONROY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-359-2256
Mailing Address - Street 1:660 S 200 E STE 250
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3846
Mailing Address - Country:US
Mailing Address - Phone:801-391-0563
Mailing Address - Fax:
Practice Address - Street 1:3535 S MARKET ST STE 200
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3685
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy