Healthcare Provider Details

I. General information

NPI: 1154565471
Provider Name (Legal Business Name): RITA FAYE BORDEAUX R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E. 6TH ST. BOX879
MCLAUGHLIN SD
57642
US

IV. Provider business mailing address

PO BOX 61
MC LAUGHLIN SD
57642-0061
US

V. Phone/Fax

Practice location:
  • Phone: 605-823-4458
  • Fax: 605-823-4460
Mailing address:
  • Phone: 605-823-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR028436
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: