Healthcare Provider Details

I. General information

NPI: 1861973760
Provider Name (Legal Business Name): WEST RIVER EAR NOSE AND THROAT, PROF., L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 5TH ST STE 2B
RAPID CITY SD
57701-6026
US

IV. Provider business mailing address

4940 5TH ST STE 2B
RAPID CITY SD
57701-6026
US

V. Phone/Fax

Practice location:
  • Phone: 605-791-0602
  • Fax: 605-791-0978
Mailing address:
  • Phone: 605-791-0602
  • Fax: 605-791-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0566
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK R SCHLEIFFARTH
Title or Position: MEMBER-MANAGER
Credential: M.D.
Phone: 605-791-0602