Provider Demographics
NPI:1760670525
Name:LOWER BRULE SIOUX TRIBE
Entity Type:Organization
Organization Name:LOWER BRULE SIOUX TRIBE
Other - Org Name:CHR PROGRAM LOWER BRULE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-473-8000
Mailing Address - Street 1:187 OYATE CIR
Mailing Address - Street 2:
Mailing Address - City:LOWER BRULE
Mailing Address - State:SD
Mailing Address - Zip Code:57548-8500
Mailing Address - Country:US
Mailing Address - Phone:605-473-8000
Mailing Address - Fax:605-473-5693
Practice Address - Street 1:187 OYATE CIR
Practice Address - Street 2:
Practice Address - City:LOWER BRULE
Practice Address - State:SD
Practice Address - Zip Code:57548-8500
Practice Address - Country:US
Practice Address - Phone:605-473-8000
Practice Address - Fax:605-473-5693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOWER BRULE SIOUX TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9515200Medicaid