Healthcare Provider Details

I. General information

NPI: 1023137890
Provider Name (Legal Business Name): DOUGLAS ALAN HACKETT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 E SULLY AVE
PIERRE SD
57501-4104
US

IV. Provider business mailing address

1112 E SULLY AVE
PIERRE SD
57501-4104
US

V. Phone/Fax

Practice location:
  • Phone: 605-786-3374
  • Fax:
Mailing address:
  • Phone: 605-786-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0994
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier5832770
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: