Healthcare Provider Details

I. General information

NPI: 1114472891
Provider Name (Legal Business Name): SPIRIT LAKE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVE NE
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

PO BOX 309
FORT TOTTEN ND
58335-0309
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1600
  • Fax: 701-766-1630
Mailing address:
  • Phone: 701-766-1600
  • Fax: 701-766-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ARLENE KRULISH
Title or Position: CEO
Credential:
Phone: 701-766-1607