1306120068 NPI number — MAGUIRE BOONSTRA INC

Table of content: (NPI 1306120068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306120068 NPI number — MAGUIRE BOONSTRA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGUIRE BOONSTRA INC
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:
ADVANCED PROSTHETICS CENTER
Provider Other Organization Name Type Code:
3
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:
1306120068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 W ANCHOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAKOTA DUNES
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57049-5154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-232-0066
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5955 S. HWY 16
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD - SOUTH DAKOTA
Provider Business Practice Location Address Postal Code:
57701
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
605-232-0066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOONSTRA
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/PROSTHETIST
Authorized Official Telephone Number:
605-232-0066

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , 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)





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