Provider Demographics
NPI:1346220183
Name:BLACK HILLS REGIONAL EYE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:BLACK HILLS REGIONAL EYE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:605-341-2000
Mailing Address - Street 1:2800 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7374
Mailing Address - Country:US
Mailing Address - Phone:605-341-2000
Mailing Address - Fax:605-719-3211
Practice Address - Street 1:2800 3RD ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7374
Practice Address - Country:US
Practice Address - Phone:605-341-2000
Practice Address - Fax:605-719-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11143261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5490052Medicaid
SD8464Medicare ID - Type Unspecified