| Shoshone-bannock Community Health Center | |
|
Navajo Drive Bldg 70 Fort Hall ID 83203-0306 | |
| (208) 478-3995 | |
| (208) 478-4040 |
| Full Name | Shoshone-bannock Community Health Center |
|---|---|
| Speciality | Clinic/Center |
| Location | Navajo Drive Bldg 70, Fort Hall, Idaho |
| Authorized Official Name and Position | Melissa M Johnson (CREDENTIALING MANAGER) |
| Authorized Official Contact | 5178963464 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Shoshone-bannock Community Health Center Po Box 306 Fort Hall ID 83203-0306 Ph: (208) 478-3995 | Shoshone-bannock Community Health Center Navajo Drive Bldg 70 Fort Hall ID 83203-0306 Ph: (208) 478-3995 |
| NPI Number | 1225414519 |
|---|---|
| Provider Enumeration Date | 08/10/2015 |
| Last Update Date | 01/19/2022 |
| Medicare PECOS PAC ID | 5496804429 |
|---|---|
| Medicare Enrollment ID | O20190619001470 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1225414519 | NPI | - | NPPES |
| 1225414519 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Secondary |
| Provider Name | Kristy Lee Broncho |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1932323045 PECOS PAC ID: 8729116009 Enrollment ID: I20190619001747 |
| Provider Name | Jesse Tellez Hernandez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184099558 PECOS PAC ID: 5395080543 Enrollment ID: I20190619002042 |
| Provider Name | Jessie A Marshall |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1750507604 PECOS PAC ID: 5193854727 Enrollment ID: I20190619002155 |
| Provider Name | Juan Lucero |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1821463704 PECOS PAC ID: 8123451242 Enrollment ID: I20191204000416 |
| Provider Name | Daniel Jerome Hall |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1366847428 PECOS PAC ID: 8921434549 Enrollment ID: I20200130000563 |
| Provider Name | Kelly Palmer |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1184780694 PECOS PAC ID: 5991879892 Enrollment ID: I20200130001510 |
| Provider Name | Deric V Ravsten |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1154431542 PECOS PAC ID: 4688636129 Enrollment ID: I20200211000562 |
| Provider Name | Patricia Stadler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124569108 PECOS PAC ID: 0446537526 Enrollment ID: I20200212000099 |
| Provider Name | Daniel L Traughber |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1386944411 PECOS PAC ID: 9234352741 Enrollment ID: I20200213000091 |
Fort Hall Indian Health Services Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: Mission Rd, Fort Hall, ID 83203 Phone: 208-238-2400 Fax: 208-238-5463 | |
Shoshone Bannock Clinic Primary Care Clinic Medicare: Medicare Enrolled Practice Location: 717 Mission Road, Fort Hall, ID 83203 Phone: 208-238-2400 Fax: 208-238-5462 | |
Not-tsoo Gah-nee Indian Health Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 717 Mission Road, Fort Hall, ID 83203 Phone: 208-238-5400 |