Provider Demographics
NPI:1619050929
Name:SIOUX VALLEY REGIONAL HEALTH SERVICES
Entity Type:Organization
Organization Name:SIOUX VALLEY REGIONAL HEALTH SERVICES
Other - Org Name:SIOUX VALLEY LAKE PARK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-324-5356
Mailing Address - Street 1:204 MARKET ST.
Mailing Address - Street 2:P.O. BOX 627
Mailing Address - City:LAKE PARK
Mailing Address - State:IA
Mailing Address - Zip Code:51347
Mailing Address - Country:US
Mailing Address - Phone:712-832-9559
Mailing Address - Fax:712-832-3801
Practice Address - Street 1:204 MARKET ST.
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:IA
Practice Address - Zip Code:51347
Practice Address - Country:US
Practice Address - Phone:712-832-9559
Practice Address - Fax:712-832-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0689091Medicaid
IA0689091Medicaid
IA168909Medicare ID - Type UnspecifiedRHC #