Provider Demographics
NPI:1962828707
Name:OST CHR PROGRAM
Entity Type:Organization
Organization Name:OST CHR PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OST CHR PROGRAM, DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-867-5801
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-0601
Mailing Address - Country:US
Mailing Address - Phone:605-867-5801
Mailing Address - Fax:605-867-5406
Practice Address - Street 1:102 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-0601
Practice Address - Country:US
Practice Address - Phone:605-867-5801
Practice Address - Fax:605-867-5406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
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
SDPROVIDER#:9515380Medicaid