Healthcare Provider Details

I. General information

NPI: 1871807206
Provider Name (Legal Business Name): SHADOW ANESTHESIA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 10TH AVE W
MOBRIDGE SD
57601
US

IV. Provider business mailing address

403 10TH ST E
MOBRIDGE SD
57601-1813
US

V. Phone/Fax

Practice location:
  • Phone: 605-845-8271
  • Fax: 605-845-3502
Mailing address:
  • Phone: 402-802-0246
  • Fax: 605-845-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number100997
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number100997
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number55417
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number100997
License Number StateNE
# 5
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License NumberCR000953
License Number StateSD

VIII. Authorized Official

Name: MS. HOLLY VICTORIA LASHMET
Title or Position: CHIEF
Credential: CRNA
Phone: 605-845-3502