Provider Demographics
NPI:1952120354
Name:BLUE LAKE RANCHERIA
Entity type:Organization
Organization Name:BLUE LAKE RANCHERIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL ADMINSTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:707-668-7226
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:BLUE LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95525-0428
Mailing Address - Country:US
Mailing Address - Phone:707-668-7226
Mailing Address - Fax:
Practice Address - Street 1:428 CHARTIN RD
Practice Address - Street 2:
Practice Address - City:BLUE LAKE
Practice Address - State:CA
Practice Address - Zip Code:95525-9722
Practice Address - Country:US
Practice Address - Phone:707-668-5101
Practice Address - Fax:707-668-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No332U00000XSuppliersHome Delivered Meals
No385H00000XRespite Care FacilityRespite Care
No174200000XOther Service ProvidersMeals