Provider Demographics
NPI:1265856561
Name:CHEYENNE RIVER SIOUX TRIBE DIABETES CLINIC
Entity Type:Organization
Organization Name:CHEYENNE RIVER SIOUX TRIBE DIABETES CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-964-0785
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-0788
Mailing Address - Fax:605-964-1062
Practice Address - Street 1:24276 166TH STREET AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-0590
Practice Address - Country:US
Practice Address - Phone:605-964-0788
Practice Address - Fax:605-964-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546290Medicaid