Healthcare Provider Details

I. General information

NPI: 1467368407
Provider Name (Legal Business Name): SAMUEL PRAIRIE CHICKEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E FAIRLANE DR
RAPID CITY SD
57701-7207
US

IV. Provider business mailing address

405 E FAIRLANE DR
RAPID CITY SD
57701-7207
US

V. Phone/Fax

Practice location:
  • Phone: 605-307-3883
  • Fax:
Mailing address:
  • Phone: 605-600-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8919
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: