Provider Demographics
NPI:1326224627
Name:QUEEN CITY REGIONAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:QUEEN CITY REGIONAL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-642-8414
Mailing Address - Street 1:1420 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1532
Mailing Address - Country:US
Mailing Address - Phone:605-642-8414
Mailing Address - Fax:605-642-8618
Practice Address - Street 1:1420 N. 10TH STREET
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-642-8414
Practice Address - Fax:605-642-8618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty