Healthcare Provider Details

I. General information

NPI: 1215570759
Provider Name (Legal Business Name): OGLALA LAKOTA AIR RESCUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 AIRPORT RD
PINE RIDGE SD
57770-3072
US

IV. Provider business mailing address

4211 W INTERSTATE 40 STE 200
AMARILLO TX
79106-6053
US

V. Phone/Fax

Practice location:
  • Phone: 805-242-4048
  • Fax:
Mailing address:
  • Phone: 806-322-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. WADE ALBERT BLACK
Title or Position: CEO
Credential:
Phone: 214-592-2627