MEDICARE: STANDING ROCK EARLY CHILDHOOD TRACKING PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		ND
2	225X00000X	Occupational Therapist	551	ND
3	235Z00000X	Speech-Language Pathologist		ND
4	252Y00000X	Early Intervention Provider Agency		ND

General Provider Information

NPI Number	:	1184990608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANDING ROCK EARLY CHILDHOOD TRACKING PROGRAM

Provider Business Mailing Address
First Line	:	PO BOX 697
Second Line	:
City	:	FT. YATES
State	:	ND
Zip	:	58538
Country	:	US
Telephone Number	:	701-854-3678
Fax Number	:	701-854-7181

Provider Business Practice Location Address
First Line	:	001 STANDING ROCK AVENUE
Second Line	:
City	:	FT. YATES
State	:	ND
Zip	:	58538
Country	:	US
Telephone Number	:	701-854-3678
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. GEORGE D STARR
Credential	:
Telephone Number	:	701-854-3678

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	03/29/2012

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