Healthcare Provider Details

I. General information

NPI: 1104068428
Provider Name (Legal Business Name): CHEYENNE RIVER SIOUX TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15607 1ST AVE
LAPLANTE SD
57652-0000
US

IV. Provider business mailing address

PO BOX 590
EAGLE BUTTE SD
57625-0590
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-0772
  • Fax: 605-964-1399
Mailing address:
  • Phone: 605-964-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAMONA SIMON
Title or Position: TRIBAL HEALTH CEO
Credential: RN
Phone: 605-964-0785