Provider Demographics
NPI:1578790986
Name:TRIBAL CLINIC
Entity Type:Organization
Organization Name:TRIBAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE/CHS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CHS
Authorized Official - Phone:605-997-2642
Mailing Address - Street 1:701 W BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1529
Mailing Address - Country:US
Mailing Address - Phone:605-997-3844
Mailing Address - Fax:605-997-3694
Practice Address - Street 1:701 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1529
Practice Address - Country:US
Practice Address - Phone:605-997-3844
Practice Address - Fax:605-997-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH2183302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization