Provider Demographics
NPI:1285987735
Name:PONCA TRIBE OF NEBRASKA
Entity type:Organization
Organization Name:PONCA TRIBE OF NEBRASKA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-734-5275
Mailing Address - Street 1:1800 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-2458
Mailing Address - Country:US
Mailing Address - Phone:402-371-8834
Mailing Address - Fax:402-731-7564
Practice Address - Street 1:1800 SYRACUSE AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-2458
Practice Address - Country:US
Practice Address - Phone:402-371-8834
Practice Address - Fax:402-371-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental