Healthcare Provider Details

I. General information

NPI: 1720025190
Provider Name (Legal Business Name): REGIONAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 CHARLES ST
DEADWOOD SD
57732-1303
US

IV. Provider business mailing address

71 CHARLES ST
DEADWOOD SD
57732-1303
US

V. Phone/Fax

Practice location:
  • Phone: 605-717-6431
  • Fax: 605-719-6470
Mailing address:
  • Phone: 605-717-6431
  • Fax: 605-719-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number42-005-460372453E
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateSD

VIII. Authorized Official

Name: TRACI MATTHEW
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 605-717-6431