Healthcare Provider Details

I. General information

NPI: 1538941794
Provider Name (Legal Business Name): BLACK HILLS MOBILE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 HAINES AVE STE D
RAPID CITY SD
57701-2453
US

IV. Provider business mailing address

PO BOX 2480
RAPID CITY SD
57709-2480
US

V. Phone/Fax

Practice location:
  • Phone: 605-770-8320
  • Fax:
Mailing address:
  • Phone: 605-770-8320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYLE DAVID LARSON
Title or Position: CEO
Credential: APRN
Phone: 605-770-8320