Provider Demographics
NPI:1346849478
Name:ADVANCED ENT AND ALLERGY CENTER OF THE BLACK HILLS, PROF LLC
Entity Type:Organization
Organization Name:ADVANCED ENT AND ALLERGY CENTER OF THE BLACK HILLS, PROF LLC
Other - Org Name:ADVANCED ENT AND ALLERGY CENTER OF THE BLACK HILLS, PROF LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-716-6390
Mailing Address - Street 1:4940 5TH ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6026
Mailing Address - Country:US
Mailing Address - Phone:605-716-6390
Mailing Address - Fax:
Practice Address - Street 1:4940 5TH ST STE 2B
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6026
Practice Address - Country:US
Practice Address - Phone:605-716-6390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center