| Details | Last Recertification Date | Update | Recertification | 1/29/2024 4:57:24 PM | 2/11/2025 11:49:48 AM | 2/11/2025 11:49 AM |
| Contacts | Authorizing Official | Update | Change Request | Newell, Dale
Interim-CEO
Toiyabe Indian Health Project
7608738464-237 | Lent, Earl William
CEO
Toiyabe Indian Health Project
7608738464 | 1/29/2025 12:58 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2023 2:32:43 PM | 1/29/2024 4:57:24 PM | 1/29/2024 4:57 PM |
| Contacts | Authorizing Official | Update | Change Request | Herman, Joseph Allen
CEO
Toiyabe Indian Health Project, Inc.
7608738464-243 | Newell, Dale
Interim-CEO
Toiyabe Indian Health Project
7608738464-237 | 10/23/2023 7:01 AM |
| Details | Last Recertification Date | Update | Recertification | 2/17/2022 1:35:33 PM | 1/31/2023 2:32:43 PM | 1/31/2023 2:32 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1659433191 | 3/14/2022 12:15 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | CA | 3/14/2022 12:15 PM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2021 8:33:58 AM | 2/17/2022 1:35:33 PM | 2/17/2022 1:35 PM |
| Addresses | Main Address | Update | Change Request |
73 CAMP ANTELOPE ROAD
COLEVILLE, CA 96107 |
199 Twin Lakes Rd.
Bridgeport, CA 93517 | 7/16/2021 10:09 AM |
| Contacts | Authorizing Official | Update | Change Request | Novak, Kori
CEO
Toiyabe Indian Health Project
7607838464 | Herman, Joseph Allen
CEO
Toiyabe Indian Health Project, Inc.
7608738464-243 | 7/16/2021 10:09 AM |
| Details | Entity Subname | Update | Change Request | Coleville CLINIC | Bridgeport Clinic | 7/16/2021 10:09 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1093720609 ( ) | | 2/8/2021 8:33 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1093720609 | 2/8/2021 8:33 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 2/8/2021 8:33 AM |
| Contacts | Primary Contact | Update | Recertification | DiRisio, Fred
Pharmacy Director
Toiyabe Indian Health Project Inc.
7608738464 | Vargas, Lisa Michelle
Credentialing Specialist
Toiyabe Indian Health Project, Inc.
7608738464-225 | 2/8/2021 8:33 AM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 1:45:26 PM | 2/8/2021 8:33:58 AM | 2/8/2021 8:33 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 1:18:16 PM | 1/28/2020 1:45:26 PM | 1/28/2020 1:45 PM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2018 1:40:51 PM | 1/29/2019 1:18:16 PM | 1/29/2019 1:18 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Curley, Amber
CEO
Toiyabe Indian Health Project, Inc.
7608738464 | Novak, Kori
CEO
Toiyabe Indian Health Project
7607838464 | 1/10/2019 7:23 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Breuninger, Trula A
Chief Executive Officer
Toiyabe Indian Health Project
7608738464 | Curley, Amber
CEO
Toiyabe Indian Health Project, Inc.
7608738464 | 6/25/2018 9:53 AM |
| Addresses | Billing Address | Update | Recertification | TOIYABE INDIAN HEALTH PROJECT, INC.
52 TUSU LANE
BISHOP, CA 93514 | TOIYABE INDIAN HEALTH PROJECT, INC.
250 N See Vee Lane
BISHOP, CA 93514 | 2/9/2018 1:40 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2017 12:00:00 AM | 2/9/2018 1:40:51 PM | 2/9/2018 1:40 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Lent, David J.
Executive Director
7608738464 | Breuninger, Trula A
Chief Executive Officer
Toiyabe Indian Health Project
7608738464 | 2/8/2018 2:57 PM |
| Contacts | Primary Contact | Update | | DiRisio, Fred
Pharmacy Director
7608738464 | DiRisio, Fred
Pharmacy Director
Toiyabe Indian Health Project Inc.
7608738464 | 1/8/2018 6:53 PM |
| Contacts | Primary Contact | Insert | | | DiRisio, Fred
Pharmacy Director
7608738464 | 5/23/2017 7:30 AM |
| Contacts | Authorizing Official | Insert | | | Lent, David J.
Executive Director
7608738464 | 5/23/2017 7:30 AM |
| Addresses | Main Address | Insert | | |
73 CAMP ANTELOPE ROAD
COLEVILLE, CA 96107 | 1/31/2017 1:01 PM |
| Details | Last Recertification Date | Update | | 3/1/2016 12:00:00 AM | 1/31/2017 12:00:00 AM | 1/31/2017 1:01 PM |
| Details | Last Recertification Date | Update | | 2/5/2015 12:00:00 AM | 3/1/2016 12:00:00 AM | 3/1/2016 12:01 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 2/5/2015 10:57 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | FHC 115767 | 2/5/2015 10:57 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 2/5/2015 10:57 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1093720609 | 2/5/2015 10:57 AM |
| Details | Last Recertification Date | Update | | | 2/5/2015 12:00:00 AM | 2/5/2015 10:57 AM |
| Details | Last Recertification Date | Update | | 3/15/2014 12:00:00 AM | | 6/3/2014 6:01 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 4/1/2014 12:00:00 AM | | 6/3/2014 6:01 PM |
| Details | Entity Subname | Update | | CAMP ANTELOPE CLINIC | Coleville CLINIC | 6/3/2014 6:01 PM |
| Dates | Participating Approval Date | Update | | 5/13/2004 12:00:00 AM | 6/3/2014 12:00:00 AM | 6/3/2014 6:01 PM |
| Details | State | Update | | Terminated | Active | 6/3/2014 6:01 PM |
| Dates | Registration Date | Update | | 7/1/2004 12:00:00 AM | 4/9/2014 12:00:00 AM | 6/3/2014 6:01 PM |
| Dates | Start Date | Update | | 7/1/2004 12:00:00 AM | 7/1/2014 12:00:00 AM | 6/3/2014 6:01 PM |
| Terminations | Termination Date | Update | | 4/1/2014 12:00:00 AM | | 6/3/2014 6:01 PM |
| Terminations | Termination Effective Date | Update | | 4/1/2014 12:00:00 AM | | 6/3/2014 6:01 PM |
| Terminations | Termination Reason | Update | | Failure to recertify | | 6/3/2014 6:01 PM |
| Details | Comments Public | Insert | | | 6/3/14 participating 7/1/04 thru 3/31/14, not participating 4/1/14 thru 6/30/14 due to failure to recertify, re-instated based on new registration submitted in april 2014 | 6/3/2014 6:01 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/15/2014 12:00:00 AM | 3/15/2014 8:34 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 4/1/2014 12:00:00 AM | 3/15/2014 8:34 AM |
| Details | State | Update | | Active | Terminated | 3/15/2014 8:34 AM |
| Terminations | Termination Date | Update | | | 4/1/2014 12:00:00 AM | 3/15/2014 8:34 AM |
| Terminations | Termination Effective Date | Update | | | 4/1/2014 12:00:00 AM | 3/15/2014 8:34 AM |
| Terminations | Termination Reason | Update | | | Failure to recertify | 3/15/2014 8:34 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/20/2013 6:42 AM |
| Addresses | Billing Address | Insert | | | TOIYABE INDIAN HEALTH PROJECT, INC.
52 TUSU LANE
BISHOP, CA 93514 | 11/7/2011 11:41 AM |
| Details | Last Recertification Date | Insert | | | | 7/1/2004 12:00 AM |
| Details | Grant Number | Insert | | | | 7/1/2004 12:00 AM |
| Details | 340B ID | Insert | | | FQHC638021A | 7/1/2004 12:00 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/1/2004 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/1/2004 12:00 AM |
| Details | Medicare Provider Number | Insert | | | | 7/1/2004 12:00 AM |
| Details | Entity Name | Insert | | | TOIYABE INDIAN HEALTH PROJECT, INC. | 7/1/2004 12:00 AM |
| Details | Program Code | Insert | | | FQHC638 | 7/1/2004 12:00 AM |
| Details | Entity Subname | Insert | | | CAMP ANTELOPE CLINIC | 7/1/2004 12:00 AM |
| Dates | Participating Approval Date | Insert | | | 5/13/2004 12:00:00 AM | 7/1/2004 12:00 AM |
| Details | State | Insert | | | Active | 7/1/2004 12:00 AM |
| Dates | Registration Date | Insert | | | 7/1/2004 12:00:00 AM | 7/1/2004 12:00 AM |
| Dates | Signed By Date | Insert | | | | 7/1/2004 12:00 AM |
| Dates | Start Date | Insert | | | 7/1/2004 12:00:00 AM | 7/1/2004 12:00 AM |
| Terminations | Termination Comments | Insert | | | | 7/1/2004 12:00 AM |
| Terminations | Termination Date | Insert | | | | 7/1/2004 12:00 AM |
| Terminations | Termination Effective Date | Insert | | | | 7/1/2004 12:00 AM |
| Terminations | Termination Reason | Insert | | | | 7/1/2004 12:00 AM |
| Details | Comments Public | Insert | | | NEW SITE 07/01/2004 | 7/1/2004 12:00 AM |