Basic Information
| Provider Information | |||||||||
| NPI: | 1356663256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE RIDGE IHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1201 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577701201 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 EAST HWY 18 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577701201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | WITT | ||||||||
| AuthorizedOfficialFirstName: | NICHOLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ER SUP. | ||||||||
| AuthorizedOfficialTelephone: | 6058673067 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 672139 | TX | Y | Hospitals | General Acute Care Hospital |
No ID Information.