=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144570995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAYTI MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 MAIN AVE
-----------------------------------------------------
City | HAYTI
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57241-0238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-783-3030
-----------------------------------------------------
Fax | 605-783-1320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 MAIN AVE
-----------------------------------------------------
City | HAYTI
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57241-0238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-783-3030
-----------------------------------------------------
Fax | 605-783-1320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MR. MITCHELL P. JENNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-783-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | CP000033
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------