Provider Demographics
NPI:1003208257
Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Entity Type:Organization
Organization Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:LACREEK DISTRICT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SYSTEM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:AKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-867-3032
Mailing Address - Street 1:119 SOUTH 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:SD
Mailing Address - Zip Code:57551
Mailing Address - Country:US
Mailing Address - Phone:605-685-2800
Mailing Address - Fax:
Practice Address - Street 1:119 SOUTH 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:SD
Practice Address - Zip Code:57551
Practice Address - Country:US
Practice Address - Phone:605-685-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-25
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5949000Medicaid
430098OtherCCN