Healthcare Provider Details

I. General information

NPI: 1740387059
Provider Name (Legal Business Name): SPIRIT LAKE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7686 EPHRIAM HILL ROAD
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

PO BOX 480
FORT TOTTEN ND
58335-0480
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-4223
  • Fax: 701-766-4878
Mailing address:
  • Phone: 701-766-4223
  • Fax: 701-766-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number142
License Number StateND

VIII. Authorized Official

Name: ELTON GREYWATER
Title or Position: MANAGER
Credential:
Phone: 701-766-4223