1053515783 NPI number — SPIRIT LAKE TRIBE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053515783 NPI number — SPIRIT LAKE TRIBE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPIRIT LAKE TRIBE
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:
SPIRIT LAKE EMS
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:
1053515783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 449
Provider Second Line Business Mailing Address:
PO BOX 449
Provider Business Mailing Address City Name:
FORT TOTTEN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58335-0449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-766-1714
Provider Business Mailing Address Fax Number:
701-766-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1403 BRUNSWICK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT TOTTEN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58335-0449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-766-1714
Provider Business Practice Location Address Fax Number:
701-766-4878
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KATE
Authorized Official Middle Name:
I
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
701-766-1714

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  0142 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1740387059 . This is a "NPI" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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