1477569267 NPI number — CITY OF LAKE PRESTON

Table of content: (NPI 1477569267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477569267 NPI number — CITY OF LAKE PRESTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF LAKE PRESTON
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:
6
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:
1477569267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30177 422ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYNDALL
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-464-0382
Provider Business Mailing Address Fax Number:
605-589-3672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 3RD ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PRESTON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57249-0397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-847-4140
Provider Business Practice Location Address Fax Number:
605-847-4140
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
BONNIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
605-847-4140

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0424 , 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: 9000340 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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