Provider Demographics
NPI:1497944953
Name:BLACK HILLS VISION CARE PROF LLC
Entity Type:Organization
Organization Name:BLACK HILLS VISION CARE PROF LLC
Other - Org Name:BLACK HILLS VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:TRIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-892-2020
Mailing Address - Street 1:1830 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-2089
Mailing Address - Country:US
Mailing Address - Phone:605-892-2020
Mailing Address - Fax:
Practice Address - Street 1:1830 5TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2089
Practice Address - Country:US
Practice Address - Phone:605-892-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000480182Medicaid
WY112944900Medicaid
SD429OtherDAKOTACARE
SD9201762Medicaid
SD0075127OtherBC/BS
MT0000480182Medicaid
SD0075127OtherBC/BS
SD6257020001Medicare NSC