Healthcare Provider Details

I. General information

NPI: 1043435746
Provider Name (Legal Business Name): BLACK HILLS OPTICAL LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 5TH AVE
BELLE FOURCHE SD
57717
US

IV. Provider business mailing address

1830 5TH AVE
BELLE FOURCHE SD
57717
US

V. Phone/Fax

Practice location:
  • Phone: 605-892-4411
  • Fax:
Mailing address:
  • Phone: 605-892-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DECEMBER WHITE
Title or Position: OPTICIAN
Credential:
Phone: 605-892-4411