Provider Demographics
NPI:1861827743
Name:STANDING ROCK SIOUX TRIBE
Entity Type:Organization
Organization Name:STANDING ROCK SIOUX TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMITTE CHAIRMAN OF THE HEALTH EDU
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:TAKEN ALIVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-854-8500
Mailing Address - Street 1:P.O. BOX D
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538
Mailing Address - Country:US
Mailing Address - Phone:701-854-8500
Mailing Address - Fax:701-854-8530
Practice Address - Street 1:139 PROPOSAL AVE
Practice Address - Street 2:STANDING ROCK SIOUX TRIBE
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-8500
Practice Address - Fax:701-854-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty