Healthcare Provider Details

I. General information

NPI: 1144465154
Provider Name (Legal Business Name): SOUTHEAST AREA COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W CEDAR ST
BERESFORD SD
57004-1524
US

IV. Provider business mailing address

1109 W CEDAR ST
BERESFORD SD
57004-1524
US

V. Phone/Fax

Practice location:
  • Phone: 605-763-5096
  • Fax: 605-763-2260
Mailing address:
  • Phone: 605-763-5096
  • Fax: 605-763-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DEAN R LINDSTROM
Title or Position: DIRECTOR
Credential: EDD
Phone: 605-763-5096