Provider Demographics
NPI:1376819409
Name:BLACK HILLS HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:BLACK HILLS HEALTH AND WELLNESS CENTER
Other - Org Name:BLACK HILLS HEALTH AND WELLNESS CENTER OF FAITH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC ASSISTANT BILLING MANA
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-341-7500
Mailing Address - Street 1:1220 MT RUSHMORE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-8264
Mailing Address - Country:US
Mailing Address - Phone:605-341-7500
Mailing Address - Fax:605-341-7903
Practice Address - Street 1:112 N 2ND AVE W
Practice Address - Street 2:
Practice Address - City:FAITH
Practice Address - State:SD
Practice Address - Zip Code:57626-0000
Practice Address - Country:US
Practice Address - Phone:605-341-7500
Practice Address - Fax:605-341-7500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK HILLS HEALTH AND WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD994111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0004738OtherBCBS
SDS41557Medicare PIN