Provider Demographics
NPI:1063602365
Name:ROSEBUD SIOUX TRIBE ALCOHOL DRUG TREATMENT PROGRAM
Entity type:Organization
Organization Name:ROSEBUD SIOUX TRIBE ALCOHOL DRUG TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCIDA
Authorized Official - Middle Name:BEATRICE
Authorized Official - Last Name:EAGLE BEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCDCIII
Authorized Official - Phone:605-747-2342
Mailing Address - Street 1:PO BOX 348, #7 HOSPITAL LANE
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570
Mailing Address - Country:US
Mailing Address - Phone:605-747-2342
Mailing Address - Fax:605-747-2111
Practice Address - Street 1:#7 HOSPITAL LANE
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570
Practice Address - Country:US
Practice Address - Phone:605-747-2342
Practice Address - Fax:605-747-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9515310Medicaid