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Organization
SHOSHONE BANNOCK TRIBES
Active
Organization
SHOSHONE BANNOCK TRIBES
Active
Other names
SHOSHONE BANNOCK CLINIC PODIATRY GROUP
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ANGELA MENDEZ (TRIBAL HEALTH DIRECTOR)
(208) 478-3994
Entity
Organization
Contact information
Practice address
717 MISSION ROAD, FORT HALL, ID 83203
(208) 238-5421
(208) 238-5462
Mailing address
PO BOX 306, PIMA DRIVE, FORT HALL, ID 83203-0306
(208) 478-3994
(208) 478-3943
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8066486
—
ID
Enumeration date
05/17/2007
Last updated
08/22/2020
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