Healthcare Provider Details

I. General information

NPI: 1316311087
Provider Name (Legal Business Name): LOWER SIOUX INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39648 RESERVATION HIGHWAY 3
MORTON MN
56270-0308
US

IV. Provider business mailing address

P.O. BOX 308 39527 RESERVATION HIGHWAY 1
MORTON MN
56270-0308
US

V. Phone/Fax

Practice location:
  • Phone: 507-697-8900
  • Fax:
Mailing address:
  • Phone: 507-697-8617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT LARSEN
Title or Position: CHAIRMAN
Credential:
Phone: 507-697-8618