1073330064 NPI number — SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION

Table of content: (NPI 1073330064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073330064 NPI number — SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073330064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGENCY VILLAGE
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57262-0509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-698-3911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12554 BIA HIGHWAY 711
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AGENCY VILLAGE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57262-7409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-698-3911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ELISE
Authorized Official Middle Name:
Authorized Official Title or Position:
TRIBAL HEALTH DIRECTOR
Authorized Official Telephone Number:
605-698-8315

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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