Healthcare Provider Details

I. General information

NPI: 1427006907
Provider Name (Legal Business Name): WELLSPRING WHOLISTIC CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 S WALNUT ST
FREEMAN SD
57029
US

IV. Provider business mailing address

PO BOX 73
FREEMAN SD
57029
US

V. Phone/Fax

Practice location:
  • Phone: 605-925-7002
  • Fax:
Mailing address:
  • Phone: 605-925-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LINDA KOTZEA
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 605-925-7002