Provider Demographics
NPI:1174625446
Name:COLVILLE CONFEDERATED TRIBES
Entity type:Organization
Organization Name:COLVILLE CONFEDERATED TRIBES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH AND HUMAN SERVICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-634-2433
Mailing Address - Street 1:1 COLVILLE STREET
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:509-634-2433
Mailing Address - Fax:509-634-2781
Practice Address - Street 1:1 COLVILLE STREET
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:509-634-2433
Practice Address - Fax:509-634-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8027476Medicaid