MEDICARE: DR. KATHRYN OPBROEK HAIVALA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	502	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	119816500	OTHER	WY	EQUALITY CARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4995272	OTHER	SD	BLUE CROSS

General Provider Information

NPI Number	:	1477564771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHRYN OPBROEK HAIVALA OD

Provider Business Mailing Address
First Line	:	1710 NORTH AVE
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783
Country	:	US
Telephone Number	:	605-642-8480
Fax Number	:	605-642-8185

Provider Business Practice Location Address
First Line	:	1710 NORTH AVE
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783
Country	:	US
Telephone Number	:	605-642-8480
Fax Number	:	605-642-8185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/17/2012

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