Healthcare Provider Details

I. General information

NPI: 1588865794
Provider Name (Legal Business Name): SPIRIT LAKE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/23/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7527 EPHRAIM HILL ROAD
FORT TOTTEN ND
58335-0088
US

IV. Provider business mailing address

7527 EPHRAIM HILL ROAD
FORT TOTTEN ND
58335-0088
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-4285
  • Fax: 701-766-1229
Mailing address:
  • Phone: 701-766-4285
  • Fax: 701-766-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number814
License Number StateND

VIII. Authorized Official

Name: MS. LINDA S PELTIER
Title or Position: 3RD PARTY BILLING MANAGER
Credential:
Phone: 701-766-1667