Provider Demographics
NPI:1366471666
Name:WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER
Entity Type:Organization
Organization Name:WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER
Other - Org Name:SISSE-WHAPETON OYATE HEALTH CARE CENTER AND SISSETON INDIAN HEALTH SER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-698-7606
Mailing Address - Street 1:100 LAKE TRAVERSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262
Mailing Address - Country:US
Mailing Address - Phone:605-698-7606
Mailing Address - Fax:605-742-3882
Practice Address - Street 1:100 LAKE TRAVERSE DRIVE
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:605-742-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549030Medicaid
SD5549030Medicaid
HS2177Medicare PIN