Healthcare Provider Details

I. General information

NPI: 1548444862
Provider Name (Legal Business Name): PINE RIDGE INDIAN HEALTH SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 1ST ST
WANBLEE SD
57577
US

IV. Provider business mailing address

PO BOX 1201
PINE RIDGE SD
57770-1201
US

V. Phone/Fax

Practice location:
  • Phone: 605-462-6155
  • Fax:
Mailing address:
  • Phone: 605-867-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RHONDA M AKERS
Title or Position: HEALTH SYSTEMS SPECIALIST
Credential:
Phone: 605-867-3032