Provider Demographics
NPI:1194461541
Name:PROFILE PLAN, LLC
Entity Type:Organization
Organization Name:PROFILE PLAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PRODUCT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-376-6659
Mailing Address - Street 1:4800 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2239
Mailing Address - Country:US
Mailing Address - Phone:605-376-6659
Mailing Address - Fax:
Practice Address - Street 1:4800 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2239
Practice Address - Country:US
Practice Address - Phone:605-376-6659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Single Specialty