Provider Demographics
NPI:1861120552
Name:CHEYENNE RIVER BREAST & CERVICAL CANCER EARLY DETECTION PROGRAM
Entity type:Organization
Organization Name:CHEYENNE RIVER BREAST & CERVICAL CANCER EARLY DETECTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-964-0785
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-0556
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH ST
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-8141
Practice Address - Country:US
Practice Address - Phone:605-964-0736
Practice Address - Fax:605-964-1176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHEYENNE RIVER SIOUX TRIBE FIELD HEALTH CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-10
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center