Healthcare Provider Details

I. General information

NPI: 1508275090
Provider Name (Legal Business Name): NISSA KVIDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

IV. Provider business mailing address

6822 PORTHCAWL CT
RAPID CITY SD
57702-6972
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-8230
  • Fax:
Mailing address:
  • Phone: 701-740-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8721
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1688
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: