Healthcare Provider Details

I. General information

NPI: 1669723441
Provider Name (Legal Business Name): DESIREE MCINTYRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W HAVENS AVE SUITE 103
MITCHELL SD
57301-4366
US

IV. Provider business mailing address

PO BOX 1284
MITCHELL SD
57301-7284
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-6044
  • Fax: 605-995-6044
Mailing address:
  • Phone: 605-995-6044
  • Fax: 605-995-6044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0288
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: