MEDICARE: SHANDA ROSE BRAGG RDMS

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	247200000X	Other Technician	2471S1302X	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101870	OTHER	SD	ARDMS

General Provider Information

NPI Number	:	1508292095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANDA ROSE BRAGG RDMS

Provider Business Mailing Address
First Line	:	6709 S MINNESOTA AVE
Second Line	:	SUITE 203
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2592
Country	:	US
Telephone Number	:	605-274-2525
Fax Number	:	605-274-0620

Provider Business Practice Location Address
First Line	:	6709 S MINNESOTA AVE
Second Line	:	SUITE 203
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2592
Country	:	US
Telephone Number	:	605-274-2525
Fax Number	:	605-274-0620

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

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	09/17/2013

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