1932769718 NPI number — SSD CARE OF SD, LLC

Table of content: (NPI 1932769718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932769718 NPI number — SSD CARE OF SD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSD CARE OF SD, LLC
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:
1932769718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WOODMONT BLVD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-733-2064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 W 22ND ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-733-2064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EADIE
Authorized Official First Name:
EDWARD LELAND
Authorized Official Middle Name:
HUTTON
Authorized Official Title or Position:
MANAGING EMPLOYEE
Authorized Official Telephone Number:
615-733-2064

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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