Healthcare Provider Details

I. General information

NPI: 1730586736
Provider Name (Legal Business Name): WINNER SURGERY CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E 8TH ST SUITE 202
WINNER SD
57580-2634
US

IV. Provider business mailing address

825 E 8TH ST SUITE 202
WINNER SD
57580-2634
US

V. Phone/Fax

Practice location:
  • Phone: 605-842-1612
  • Fax: 605-842-3837
Mailing address:
  • Phone: 605-842-1612
  • Fax: 605-842-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDB059482
License Number StateSD

VIII. Authorized Official

Name: RICK J WAGNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 605-842-1612