Provider Demographics
NPI:1659530707
Name:CHEYENNE RIVER SIOUX TRIBE
Entity Type:Organization
Organization Name:CHEYENNE RIVER SIOUX TRIBE
Other - Org Name:DIABETES PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL HEALTH CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-964-0785
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-4843
Mailing Address - Fax:605-964-1176
Practice Address - Street 1:24276 166TH ST
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-8141
Practice Address - Country:US
Practice Address - Phone:605-964-0772
Practice Address - Fax:605-964-1176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHEYENNE RIVER SIOUX TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-04
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD20-001-E-ST332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies