Healthcare Provider Details

I. General information

NPI: 1255560066
Provider Name (Legal Business Name): MIKA J TIBBS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N MAIN ST
EAGLE BUTTE SD
57625-1012
US

IV. Provider business mailing address

PO BOX 1012
EAGLE BUTTE SD
57625-1012
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-3004
  • Fax:
Mailing address:
  • Phone: 605-964-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR037153
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: