Provider Demographics
NPI:1619559739
Name:PAN, TILE
Entity Type:Individual
Prefix:
First Name:TILE
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 MOUNT RUSHMORE RD STE B
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5102
Mailing Address - Country:US
Mailing Address - Phone:605-545-8543
Mailing Address - Fax:
Practice Address - Street 1:2415 MOUNT RUSHMORE RD STE B
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5102
Practice Address - Country:US
Practice Address - Phone:605-545-8543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty