Provider Demographics
NPI:1063494789
Name:WALL HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:WALL HEALTH SERVICES, INC.
Other - Org Name:WALL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-279-2149
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:SD
Mailing Address - Zip Code:57790-0423
Mailing Address - Country:US
Mailing Address - Phone:605-279-2149
Mailing Address - Fax:605-279-2139
Practice Address - Street 1:112 7TH AVE
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:SD
Practice Address - Zip Code:57790-0423
Practice Address - Country:US
Practice Address - Phone:605-279-2149
Practice Address - Fax:605-279-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300040Medicaid
SD4999946OtherBCBS # FOR WALL CLINIC
SD5300040Medicaid
SD4999946OtherBCBS # FOR WALL CLINIC