Provider Demographics
NPI:1437188729
Name:FLANDREAU SANTEE SIOUX TRIBE
Entity Type:Organization
Organization Name:FLANDREAU SANTEE SIOUX TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER/ CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-573-5166
Mailing Address - Street 1:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-0329
Mailing Address - Country:US
Mailing Address - Phone:605-997-2642
Mailing Address - Fax:605-997-2225
Practice Address - Street 1:403 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028
Practice Address - Country:US
Practice Address - Phone:605-997-2642
Practice Address - Fax:605-997-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546010Medicaid
SD5546010Medicaid