Provider Demographics
NPI:1558395848
Name:EAGLE BUTTE INDIAN HEALTH SERVICE HOSPITAL
Entity Type:Organization
Organization Name:EAGLE BUTTE INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-964-7724
Mailing Address - Street 1:24276 166TH STREET AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1012
Mailing Address - Country:US
Mailing Address - Phone:605-964-7724
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH STREET
Practice Address - Street 2:AIRPORT ROAD
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-1012
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549080Medicaid
SD8HE051Medicare UPIN
HSZ039Medicare PIN
430083Medicare Oscar/Certification
PHS000Medicare UPIN