Provider Demographics
NPI:1033189683
Name:BROTEN, LAURA (RPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BROTEN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 S HIGHWAY 16
Mailing Address - Street 2:PO BOX 6850
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8708
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:605-341-7062
Practice Address - Street 1:7220 S HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8708
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:605-341-7062
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834890Medicaid
P00397949OtherMEDICARE RAILROAD PTAN
SD1254560001OtherCIGNA MEDICARE
SD100449Medicare ID - Type Unspecified
SDS100449Medicare PIN
SD1254560001OtherCIGNA MEDICARE