Organization
SHOSHONE BANNOCK TRIBES, INC
Active
Parent organization
SHOSHONE BANNOCK TRIBES, INC
Other names
Shoshone Bannock Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
SHOSHONE BANNOCK TRIBES, INC
Authorized official
MS. ANGELA MENDEZ (TRIBAL HEALTH DIRECTOR)
(208) 478-3744
Entity
Organization
Contact information
Practice address
717 MISSION ROAD, FORT HALL, ID 83203-0306
(208) 238-2400
(208) 238-5462
Mailing address
PO BOX 306, FORT HALL, ID 83203-0306
(208) 238-2400
(208) 238-5462
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002264100
—
ID
05
—
003399100
—
ID
05
—
8063500
—
ID
05
—
8064977
—
ID
05
—
80662922
—
ID
05
—
806648600
—
ID
Enumeration date
01/22/2007
Last updated
01/25/2010
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