Provider Demographics
NPI:1316311087
Name:LOWER SIOUX INDIAN COMMUNITY
Entity type:Organization
Organization Name:LOWER SIOUX INDIAN COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-697-8618
Mailing Address - Street 1:P.O. BOX 308
Mailing Address - Street 2:39527 RESERVATION HIGHWAY 1
Mailing Address - City:MORTON
Mailing Address - State:MN
Mailing Address - Zip Code:56270-0308
Mailing Address - Country:US
Mailing Address - Phone:507-697-8617
Mailing Address - Fax:
Practice Address - Street 1:39648 RESERVATION HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MN
Practice Address - Zip Code:56270-0308
Practice Address - Country:US
Practice Address - Phone:507-697-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care