Provider Demographics
NPI:1679598320
Name:DAKOTA PSYCHIATRY CLINIC PC
Entity Type:Organization
Organization Name:DAKOTA PSYCHIATRY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-348-6365
Mailing Address - Street 1:419 QUINCY STREET
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-348-6365
Mailing Address - Fax:605-348-9408
Practice Address - Street 1:419 QUINCY STREET
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-348-6365
Practice Address - Fax:605-348-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD 22472084P0800X
TXE26842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4998327OtherBCBS
SD7100080Medicaid
4998327OtherBCBS