Healthcare Provider Details

I. General information

NPI: 1245681758
Provider Name (Legal Business Name): JOHN A STODDARD LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK A STODDARD LAC

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 KANSAS AVE SE
HURON SD
57350-2517
US

IV. Provider business mailing address

357 KANSAS AVE SE
HURON SD
57350-2517
US

V. Phone/Fax

Practice location:
  • Phone: 605-352-8596
  • Fax: 605-352-7001
Mailing address:
  • Phone: 605-352-8596
  • Fax: 605-352-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number99041042
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: