Healthcare Provider Details

I. General information

NPI: 1821092818
Provider Name (Legal Business Name): JAMES D KIENITZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 LAZELLE ST
STURGIS SD
57785
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MEDICAL STAFF SERVICES
RAPID CITY SD
57701-6000
US

V. Phone/Fax

Practice location:
  • Phone: 605-720-2600
  • Fax: 605-720-2611
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number407
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: