Provider Demographics
NPI:1053515783
Name:SPIRIT LAKE TRIBE
Entity type:Organization
Organization Name:SPIRIT LAKE TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATE
Authorized Official - Middle Name:I
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:701-766-1714
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:PO BOX 449
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0449
Mailing Address - Country:US
Mailing Address - Phone:701-766-1714
Mailing Address - Fax:701-766-4878
Practice Address - Street 1:1403 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335-0449
Practice Address - Country:US
Practice Address - Phone:701-766-1714
Practice Address - Fax:701-766-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0142341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1740387059OtherNPI
ND70727Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION #