1104060128 NPI number — OGLALA SIOUX TRIBE OTITIS MEDIA

Table of content: (NPI 1104060128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104060128 NPI number — OGLALA SIOUX TRIBE OTITIS MEDIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OGLALA SIOUX TRIBE OTITIS MEDIA
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:
OGLALA SIOUX TRIBE OTITIS MEDIA
Provider Other Organization Name Type Code:
3
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:
1104060128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 EAST HIGHWAY IHS
Provider Second Line Business Mailing Address:
PO BOX 1201
Provider Business Mailing Address City Name:
PINE RIDGE
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57770-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-867-3004
Provider Business Mailing Address Fax Number:
605-867-3374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 EAST HIGHWAY IHS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE RIDGE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57770-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-867-3004
Provider Business Practice Location Address Fax Number:
605-867-3374
Provider Enumeration Date:
04/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK FEATHER
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
MEDICAL INSURANCE BILLER AND CODER
Authorized Official Telephone Number:
605-867-3004

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  018A , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: R020891 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: 4820 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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