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General NPI Number Information
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NPI Number | 1619347622
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Entity Type | Organization
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Legal Business Name | LORI KAY EGEBERG
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Dates
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Enumeration Date | 10/02/2015
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Last Update Date | 10/02/2015
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Provider Practice Location Address
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Address Line | 511 6TH ST
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City | BROOKINGS
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State | SD
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Zip | 57006-1436
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Country | US
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Telephone | 605-692-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 511 6TH ST
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City | BROOKINGS
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State | SD
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Zip | 57006-1436
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Country | US
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Telephone | 605-692-5600
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LORI KAY EGEBERG
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Credential |
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Telephone | 605-692-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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