1063553287 NPI number — BLACK HILLS ORTHOTICS & PROSTHETICS

Table of content: (NPI 1063553287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063553287 NPI number — BLACK HILLS ORTHOTICS & PROSTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK HILLS ORTHOTICS & PROSTHETICS
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:
1063553287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3639 AVENUE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSBLUFF
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69361-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-632-4641
Provider Business Mailing Address Fax Number:
308-632-6247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 ELM AVE
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:
57701-3846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-341-8577
Provider Business Practice Location Address Fax Number:
605-341-7656
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARRELL
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER CERTIFIED ORTHOTIST
Authorized Official Telephone Number:
605-341-8577

Provider Taxonomy Codes

  • Taxonomy code: 1744P3200X , with the licence number:  53-001-E-ST , 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: 9151810 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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