Basic Information
| Provider Information | |||||||||
| NPI: | 1548444862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE RIDGE INDIAN HEALTH SERVICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WANBLEE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1201 | ||||||||
| Address2: | |||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577701201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058675131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WANBLEE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054626155 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2007 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AKERS | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH SYSTEMS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6058673032 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 5540040 | 05 | SC | MEDICAID | 430098 | 01 | CCN | OTHER |