Healthcare Provider Details

I. General information

NPI: 1699754143
Provider Name (Legal Business Name): MISSOURI BREAKS INDUSTRIES RESEARCH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S WILLOW ST
EAGLE BUTTE SD
57625
US

IV. Provider business mailing address

PO BOX 1824
EAGLE BUTTE SD
57625-1824
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-3418
  • Fax: 605-964-3415
Mailing address:
  • Phone: 605-964-3418
  • Fax: 605-964-3415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BLAINE O'LEARY
Title or Position: MANAGER
Credential:
Phone: 605-964-3418