Provider Demographics
NPI:1447462700
Name:SHOALWATER BAY INDIAN TRIBE
Entity type:Organization
Organization Name:SHOALWATER BAY INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-267-6766
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:TOKELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98590-0500
Mailing Address - Country:US
Mailing Address - Phone:360-267-2508
Mailing Address - Fax:360-267-1127
Practice Address - Street 1:2373 OLD TOKELAND RD
Practice Address - Street 2:
Practice Address - City:TOKELAND
Practice Address - State:WA
Practice Address - Zip Code:98590
Practice Address - Country:US
Practice Address - Phone:360-267-2508
Practice Address - Fax:360-267-1127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)