Healthcare Provider Details

I. General information

NPI: 1144437732
Provider Name (Legal Business Name): FORT YATES IHS HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NORTH RIVER ROAD
FORT YATES ND
58538-0527
US

IV. Provider business mailing address

PO BOX J
FORT YATES ND
58538-0527
US

V. Phone/Fax

Practice location:
  • Phone: 605-854-3831
  • Fax:
Mailing address:
  • Phone: 605-854-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: PAUL GEORGE BORDEAUX
Title or Position: RADIOLOGICAL TECHNICIAN
Credential:
Phone: 605-854-3831