1225090459 NPI number — DRS. TUCKER-KUDRNA-HOLEC-YOUNG EYE CARE CENTRE LLP

Table of content: (NPI 1225090459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225090459 NPI number — DRS. TUCKER-KUDRNA-HOLEC-YOUNG EYE CARE CENTRE LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS. TUCKER-KUDRNA-HOLEC-YOUNG EYE CARE CENTRE LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225090459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 JACKSON BLVD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57702-3483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-342-0777
Provider Business Mailing Address Fax Number:
605-342-7282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 JACKSON BLVD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57702-3483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-342-0777
Provider Business Practice Location Address Fax Number:
605-342-7282
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLEC
Authorized Official First Name:
BILL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
605-342-0777

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  459 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 520 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 587 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 626 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 520 . This is a "DR KUDRNA STATE LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 626 . This is a "DR. YOUNG STATE LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9201280 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9202543 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9203593 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9200363 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 587 . This is a "DR HOLEC STATE LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0040353 . This is a "WELLMARK BCBS ID NUMBER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 459 . This is a "DR TUCKER STATE LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: S40353 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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