Healthcare Provider Details

I. General information

NPI: 1104028257
Provider Name (Legal Business Name): LINDA JANE SANDVIK RN BSN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

4810 POWDERHORN DR
RAPID CITY SD
57702-4801
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2201
  • Fax: 605-355-2403
Mailing address:
  • Phone: 605-342-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR017831
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: