Organization
SHOSHONE BANNOCK TRIBES, INC
Active
Other names
Shoshone-Bannock Community Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
MELISSA M JOHNSON (CREDENTIALING MANAGER)
(517) 896-3464
Entity
Organization
Contact information
Practice address
NAVAJO DRIVE BLDG 70, FORT HALL, ID 83203-0306
(208) 478-3995
(208) 478-4040
Mailing address
PO BOX 306, FORT HALL, ID 83203-0306
(208) 478-3995
(208) 478-4040
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1225414519
—
ID
Enumeration date
08/10/2015
Last updated
01/19/2022
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