Provider Demographics
NPI:1356663256
Name:PINE RIDGE IHS
Entity Type:Organization
Organization Name:PINE RIDGE IHS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ER SUP.
Authorized Official - Prefix:MS
Authorized Official - First Name:NICHOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-867-3067
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 EAST HWY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-1201
Practice Address - Country:US
Practice Address - Phone:605-867-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX672139282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital