Provider Demographics
NPI:1740387059
Name:SPIRIT LAKE TRIBE
Entity Type:Organization
Organization Name:SPIRIT LAKE TRIBE
Other - Org Name:SPIRIT LAKE EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELTON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREYWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-4223
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0480
Mailing Address - Country:US
Mailing Address - Phone:701-766-4223
Mailing Address - Fax:701-766-4878
Practice Address - Street 1:7686 EPHRIAM HILL ROAD
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-4223
Practice Address - Fax:701-766-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1423416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND70727OtherBLUE CROSS PROVIDER
MNA610023000Medicaid
ND59890Medicaid
ND59890Medicaid