Provider Demographics
NPI:1720025190
Name:REGIONAL HEALTH
Entity Type:Organization
Organization Name:REGIONAL HEALTH
Other - Org Name:LEAD-DEADWOOD REGIONAL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-717-6431
Mailing Address - Street 1:71 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:DEADWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57732-1303
Mailing Address - Country:US
Mailing Address - Phone:605-717-6431
Mailing Address - Fax:605-719-6470
Practice Address - Street 1:71 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1303
Practice Address - Country:US
Practice Address - Phone:605-717-6431
Practice Address - Fax:605-719-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD42-005-460372453E261Q00000X
SD291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD100931Medicare PIN