Provider Demographics
NPI:1952429862
Name:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Other - Org Name:COLVILLE TRIBAL CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WHITELAW
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:509-634-2877
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0150
Mailing Address - Country:US
Mailing Address - Phone:509-634-2877
Mailing Address - Fax:509-634-2889
Practice Address - Street 1:29 CONVALESCENT CENTER BLVD.
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155-0150
Practice Address - Country:US
Practice Address - Phone:509-634-2877
Practice Address - Fax:509-634-2889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN764314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4176400Medicaid
WA4176400Medicaid