Provider Demographics
NPI:1407163207
Name:LAKOTA TIWAHE CENTER
Entity Type:Organization
Organization Name:LAKOTA TIWAHE CENTER
Other - Org Name:ROSEBUD DEVELOPMENTAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-747-2833
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:141 HOSPITAL ROAD-LAKOTA TIWAHE CENTER
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570-0040
Mailing Address - Country:US
Mailing Address - Phone:605-747-2833
Mailing Address - Fax:605-747-5479
Practice Address - Street 1:40 HOSPITAL ROAD
Practice Address - Street 2:LAKOTA TIWAHE CENTER
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-0040
Practice Address - Country:US
Practice Address - Phone:605-747-2833
Practice Address - Fax:605-747-5479
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSEBUD SIOUX TRIBE EDUCATION DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5607940Medicaid