Healthcare Provider Details

I. General information

NPI: 1669751350
Provider Name (Legal Business Name): LOIS JEAN HAZEN MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W MAIN ST
VERMILLION SD
57069-3017
US

IV. Provider business mailing address

216 W MAIN ST
VERMILLION SD
57069-3017
US

V. Phone/Fax

Practice location:
  • Phone: 605-624-6732
  • Fax: 605-624-6732
Mailing address:
  • Phone: 605-624-6732
  • Fax: 605-624-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number551
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: