Healthcare Provider Details

I. General information

NPI: 1124371992
Provider Name (Legal Business Name): WYATT NASH-KELLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 22ND AVE S
BROOKINGS SD
57006-2804
US

IV. Provider business mailing address

1208 22ND AVE S
BROOKINGS SD
57006-0284
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-2020
  • Fax: 605-692-9594
Mailing address:
  • Phone: 605-692-2020
  • Fax: 605-692-9594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number723
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: