Healthcare Provider Details

I. General information

NPI: 1932824331
Provider Name (Legal Business Name): OGLALA SIOUX TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1588 US-18
PINE RIDGE SD
57770
US

IV. Provider business mailing address

1588 US-18
PINE RIDGE SD
57770
US

V. Phone/Fax

Practice location:
  • Phone: 214-738-8707
  • Fax: 866-781-9370
Mailing address:
  • Phone: 214-738-8707
  • Fax: 866-781-9370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN KILLER
Title or Position: PRESIDENT
Credential:
Phone: 605-864-8487