Provider Demographics
NPI:1083331649
Name:SPIRIT LAKE TRIBE
Entity Type:Organization
Organization Name:SPIRIT LAKE TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-4736
Mailing Address - Street 1:7184 HWY 57
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335
Mailing Address - Country:US
Mailing Address - Phone:701-766-4736
Mailing Address - Fax:701-766-4722
Practice Address - Street 1:7184 HWY 57
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-4736
Practice Address - Fax:701-766-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)