Healthcare Provider Details

I. General information

NPI: 1760951107
Provider Name (Legal Business Name): ATLAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 KANSAS CITY ST
RAPID CITY SD
57701-3636
US

IV. Provider business mailing address

409 KANSAS CITY ST
RAPID CITY SD
57701-3636
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-2323
  • Fax: 605-348-6694
Mailing address:
  • Phone: 605-348-2323
  • Fax: 605-348-6694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ANTWAN PERCY RANDOLPH
Title or Position: OWNER
Credential: OD
Phone: 605-642-2533