Healthcare Provider Details

I. General information

NPI: 1386464402
Provider Name (Legal Business Name): SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 LAKE TRAVERSE DR STE 102
SISSETON SD
57262-7046
US

IV. Provider business mailing address

PO BOX 509
SISSETON SD
57262-0509
US

V. Phone/Fax

Practice location:
  • Phone: 833-674-3444
  • Fax:
Mailing address:
  • Phone: 605-742-3697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ELISE JOHNSON
Title or Position: TRIBAL HEALTH DIRECTOR
Credential:
Phone: 605-698-3911