Basic Information
| Provider Information | |||||||||
| NPI: | 1093228157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE RIDGE INDIAN HEALTH SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1201 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577701201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058673032 | ||||||||
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| Practice Location | |||||||||
| Address1: | EAST HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058673032 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 11/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | DUANE | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6058673040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | HSZ153 | 01 | MEDICARE PART B | OTHER |