Healthcare Provider Details

I. General information

NPI: 1043115280
Provider Name (Legal Business Name): HUMAN SERVICE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 19TH ST NE
WATERTOWN SD
57201-2823
US

IV. Provider business mailing address

123 19TH ST NE
WATERTOWN SD
57201-2823
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-0123
  • Fax: 605-886-5447
Mailing address:
  • Phone: 605-886-0123
  • Fax: 605-886-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENDRA WILDBERGER
Title or Position: ACCOUNT SPECIALIST
Credential:
Phone: 605-884-3512