Provider Demographics
NPI:1720152457
Name:SPIRIT LAKE TRIBE
Entity type:Organization
Organization Name:SPIRIT LAKE TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRPERSON
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-381-2006
Mailing Address - Street 1:416 2ND AVENUE NORTH
Mailing Address - Street 2:PO BOX 489
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335
Mailing Address - Country:US
Mailing Address - Phone:701-766-1238
Mailing Address - Fax:701-766-1260
Practice Address - Street 1:416 2ND AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1238
Practice Address - Fax:701-766-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1325Medicaid
ND1720152457Medicare UPIN
ND1325Medicaid