Healthcare Provider Details

I. General information

NPI: 1740398312
Provider Name (Legal Business Name): ROBERT CARL DOUVILLE II RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 34 & 47
FORT THOMPSON SD
57339-0200
US

IV. Provider business mailing address

HWY 34 & 47
FORT THOMPSON SD
57339-0200
US

V. Phone/Fax

Practice location:
  • Phone: 605-245-2283
  • Fax: 605-245-2150
Mailing address:
  • Phone: 605-245-2283
  • Fax: 605-245-2150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR-025435
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: