Shoshone Bannock Tribes, Inc
Organization Active NPI Clinic/Center · Fort Hall, ID
NPI 1801949763 · NPPES record last updated Jan 25, 2010
Key facts
- NPI
- 1801949763
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- Legal business name
- SHOSHONE BANNOCK TRIBES, INC
- Practice address
- 717 Mission Road
Fort Hall, ID 83203-0306 - Phone
- (208) 238-2400
- Fax
- (208) 238-5462
- NPI assigned
- Jan 22, 2007
- Organization subpart
- Yes
- Parent organization (as reported)
- SHOSHONE BANNOCK TRIBES, INC
Authorized official
- Name
- Ms. Angela Mendez
- Title
- Tribal Health Director
- Phone
- (208) 478-3744
Other NPIs on the same Medicare enrollment 1
Practitioners 15
-
Jessie A Bacon, LCSW
-
Chantelle E Bowman, PA-C
-
Rachel Ellen Peay-Goodman, FNP-BC
-
Patricia Stadler, FNP-C
-
Melissa D. Syria, LCPC
-
Kathleen Ann Baron, APRN, CNP, FNP, PNP
-
Kristy Lee Broncho, LCSW
-
Daniel Jerome Hall, LCSW
-
Emily Newberry, NP
-
Wiley D Petersen, PA-C
-
Scott Bradley Schaffer, MSN, APRN, FNP-C
-
Matthew J Wadsworth, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20190619001470 | TX | Part B Supplier - Clinic/Group Practice | 5496804429 |
Receives reassigned benefits from 11 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Fort Hall, ID |
National Provider Directory
- Part of
- Shoshone Bannock Tribes Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | Yes |
Addresses
Primary practice location
717 Mission Road
Fort Hall, ID 83203-0306
Mailing address
PO Box 306
Fort Hall, ID 83203-0306
Phone (208) 238-2400
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 002264100 | Medicaid | ID | |
| 003399100 | Medicaid | ID | |
| 8063500 | Medicaid | ID | |
| 8064977 | Medicaid | ID | |
| 806648600 | Medicaid | ID | |
| 80662922 | Medicaid | ID |
Other names
- Shoshone Bannock Clinic
Other providers in Fort Hall, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 25, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.