Healthcare Provider Details

I. General information

NPI: 1346413762
Provider Name (Legal Business Name): LESLIE RAE KERWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S RIVER ST
CHAMBERLAIN SD
57325-1525
US

IV. Provider business mailing address

211 S RIVER ST
CHAMBERLAIN SD
57325-1525
US

V. Phone/Fax

Practice location:
  • Phone: 605-234-0503
  • Fax:
Mailing address:
  • Phone: 605-234-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number176859
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: