Provider Demographics
NPI:1295348548
Name:CRST COMMUNITY HEALTH REPRESENTATIVES (CHR) PROGRAM
Entity type:Organization
Organization Name:CRST COMMUNITY HEALTH REPRESENTATIVES (CHR) PROGRAM
Other - Org Name:
Other - Org Type:
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:
Authorized Official - Phone:605-964-0785
Mailing Address - Street 1:P.O. BOX 590
Mailing Address - Street 2:24276 AIRPORT RD,
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-0728
Mailing Address - Fax:605-964-0734
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:605-964-0728
Practice Address - Fax:605-964-0734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546290Medicaid