1184303208 NPI number — SANDBULTE LLC

Table of content: (NPI 1184303208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184303208 NPI number — SANDBULTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDBULTE 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:
1184303208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 E 69TH STR.
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108-8322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-906-3329
Provider Business Mailing Address Fax Number:
877-814-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E. 69TH STR
Provider Second Line Business Practice Location Address:
SUITE 101
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-906-3329
Provider Business Practice Location Address Fax Number:
877-814-0028
Provider Enumeration Date:
07/17/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SANDBULTE
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST/OWNER
Authorized Official Telephone Number:
605-906-3329

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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