Provider Demographics
NPI:1043435746
Name:BLACK HILLS OPTICAL LLP
Entity Type:Organization
Organization Name:BLACK HILLS OPTICAL LLP
Other - Org Name:BLACK HILLS VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DECEMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-892-4411
Mailing Address - Street 1:1830 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717
Mailing Address - Country:US
Mailing Address - Phone:605-892-4411
Mailing Address - Fax:
Practice Address - Street 1:1830 5TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717
Practice Address - Country:US
Practice Address - Phone:605-892-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9280613Medicaid
SD9280613Medicaid