Healthcare Provider Details

I. General information

NPI: 1508052739
Provider Name (Legal Business Name): THERATIME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S PENDAR LN
SIOUX FALLS SD
57105-3944
US

IV. Provider business mailing address

2115 S PENDAR LN
SIOUX FALLS SD
57105-3944
US

V. Phone/Fax

Practice location:
  • Phone: 605-339-1800
  • Fax: 605-339-1239
Mailing address:
  • Phone: 605-339-1800
  • Fax: 605-339-1239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number0295
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0522
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01100452
License Number StateSD

VIII. Authorized Official

Name: MR. CORY MICHAEL FABER
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-339-1800