Healthcare Provider Details

I. General information

NPI: 1518914829
Provider Name (Legal Business Name): MELLETTE COUNTY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FIRST AND ROOSEVELT
WHITE RIVER SD
57579-0281
US

IV. Provider business mailing address

PO BOX 281
WHITE RIVER SD
57579-0281
US

V. Phone/Fax

Practice location:
  • Phone: 605-259-3121
  • Fax: 605-259-3444
Mailing address:
  • Phone: 605-259-3121
  • Fax: 605-259-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0004
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number0004
License Number StateSD

VIII. Authorized Official

Name: MRS. MARILYN SEYMOUR
Title or Position: PHYSICIAN ASSISTANT
Credential: P.A.
Phone: 605-259-3121