Healthcare Provider Details

I. General information

NPI: 1972760205
Provider Name (Legal Business Name): MICHAEL DON BARTLEY LHAD # 172
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 YORKSHIRE DR
BROOKINGS SD
57006-2446
US

IV. Provider business mailing address

2311 YORKSHIRE DR
BROOKINGS SD
57006-2446
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-7619
  • Fax: 605-697-6005
Mailing address:
  • Phone: 605-692-7619
  • Fax: 605-697-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number172
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: