Provider Demographics
NPI:1073271953
Name:SHORES CLINIC LLC
Entity Type:Organization
Organization Name:SHORES CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORES FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:CSW-PIP
Authorized Official - Phone:609-558-7834
Mailing Address - Street 1:909 S WESTMOOR DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4420
Mailing Address - Country:US
Mailing Address - Phone:609-558-7834
Mailing Address - Fax:
Practice Address - Street 1:5000 S MAC ARTHUR LN STE 104
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5407
Practice Address - Country:US
Practice Address - Phone:605-206-7373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)