1659343143 NPI number — GRACE A LAFOLLETTE CNP

Table of content: GRACE A LAFOLLETTE CNP (NPI 1659343143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659343143 NPI number — GRACE A LAFOLLETTE CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAFOLLETTE
Provider First Name:
GRACE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOURNE
Provider Other First Name:
GRACE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659343143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S. MINNESOTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 69TH ST
Provider Second Line Business Practice Location Address:
STE. 1500
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-8170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-5700
Provider Business Practice Location Address Fax Number:
605-322-5704
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  CP000282 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: CP000282 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 46022474352 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142419 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6826732 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0040478 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 12200 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140M7BO . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 25216 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 690718100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9233298 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 15766 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 22591 . This is a "BLUE CROSS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 500002297 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500026048 . This is a "RR MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: HP37123 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1663494 . This is a "ARAZ/ AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 412991028069 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1958108 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57108C022 . This is a "TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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