Provider Demographics
NPI:1629858519
Name:SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION
Entity Type:Organization
Organization Name:SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION
Other - Org Name:SISSETON-WAHPETON OYATE ASNIYAPI FIELD HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SWO TRIBAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:605-698-8315
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-0509
Mailing Address - Country:US
Mailing Address - Phone:605-742-3697
Mailing Address - Fax:605-698-4239
Practice Address - Street 1:114 LAKE TRAVERSE DR STE 102
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:833-674-3444
Practice Address - Fax:605-303-5295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISSETON WAHPETON OYATE OF THE LAKE TRAVERSE RESERVATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-29
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty