Healthcare Provider Details

I. General information

NPI: 1235600404
Provider Name (Legal Business Name): BAILEY JO KECKLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BAILEY JO HENINGER

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/13/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24337 US HIGHWAY 212
EAGLE BUTTE SD
57625-7770
US

IV. Provider business mailing address

PO BOX 860
EAGLE BUTTE SD
57625-0860
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-8000
  • Fax:
Mailing address:
  • Phone: 605-295-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR047564
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002540
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: