Healthcare Provider Details

I. General information

NPI: 1063602365
Provider Name (Legal Business Name): ROSEBUD SIOUX TRIBE ALCOHOL DRUG TREATMENT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#7 HOSPITAL LANE
ROSEBUD SD
57570
US

IV. Provider business mailing address

PO BOX 348, #7 HOSPITAL LANE
ROSEBUD SD
57570
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-2342
  • Fax: 605-747-2111
Mailing address:
  • Phone: 605-747-2342
  • Fax: 605-747-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MS. MARCIDA BEATRICE EAGLE BEAR
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A., CCDCIII
Phone: 605-747-2342