Basic Information
| Provider Information | |||||||||
| NPI: | 1033266945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1201 | ||||||||
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| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577700275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PORCUPINE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | POURIER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6058673021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 5540260 | 05 | SD | MEDICAID |