=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952591000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASCADE INTEGRATIVE MEDICINE OF SOUTH DAKOTA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2007
-----------------------------------------------------
Last Update Date | 05/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 HIGHWAY 18 BYP
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57747-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-745-5102
-----------------------------------------------------
Fax | 605-745-6707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 HIGHWAY 18 BYP
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57747-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-745-5102
-----------------------------------------------------
Fax | 605-745-6707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GERALD VERN PETERSON
-----------------------------------------------------
Credential | PHYS. ASST.
-----------------------------------------------------
Telephone | 605-745-5102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0177
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------