Provider Demographics
NPI:1508052739
Name:THERATIME INC
Entity Type:Organization
Organization Name:THERATIME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-339-1800
Mailing Address - Street 1:2115 S PENDAR LN
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3944
Mailing Address - Country:US
Mailing Address - Phone:605-339-1800
Mailing Address - Fax:605-339-1239
Practice Address - Street 1:2115 S PENDAR LN
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-3944
Practice Address - Country:US
Practice Address - Phone:605-339-1800
Practice Address - Fax:605-339-1239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD02952251P0200X
SD0522225XP0200X
SD01100452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834750Medicaid