Provider Demographics
NPI:1588865794
Name:SPIRIT LAKE TRIBE
Entity type:Organization
Organization Name:SPIRIT LAKE TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:3RD PARTY BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PELTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-1667
Mailing Address - Street 1:7527 EPHRAIM HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0088
Mailing Address - Country:US
Mailing Address - Phone:701-766-4285
Mailing Address - Fax:701-766-1229
Practice Address - Street 1:7527 EPHRAIM HILL ROAD
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335-0088
Practice Address - Country:US
Practice Address - Phone:701-766-4285
Practice Address - Fax:701-766-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8141041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27599OtherLICSW BCBS
ND27600OtherLAC BCBS