Healthcare Provider Details

I. General information

NPI: 1912083577
Provider Name (Legal Business Name): FAMILY PRACTICE ASSOCIATES OF WINNER PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E 8TH ST
WINNER SD
57580-2688
US

IV. Provider business mailing address

825 E 8TH ST
WINNER SD
57580-2688
US

V. Phone/Fax

Practice location:
  • Phone: 605-842-2626
  • Fax: 605-842-3557
Mailing address:
  • Phone: 605-842-2626
  • Fax: 605-842-3557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE PARVIN
Title or Position: CREDENTIALING
Credential:
Phone: 605-842-2626