Provider Demographics
NPI:1295824852
Name:STANDING ROCK SIOUX TRIBE
Entity type:Organization
Organization Name:STANDING ROCK SIOUX TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-854-3452
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-0974
Mailing Address - Country:US
Mailing Address - Phone:701-250-6361
Mailing Address - Fax:
Practice Address - Street 1:9311 HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538-9621
Practice Address - Country:US
Practice Address - Phone:701-854-3452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND041341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50580Medicaid
ND7210OtherBLUE CROSS
SD9011130Medicaid
SD9011130Medicaid
ND7210OtherBLUE CROSS