Provider Demographics
NPI:1720214737
Name:MONUMENT HEALTH NETWORK, INC.
Entity Type:Organization
Organization Name:MONUMENT HEALTH NETWORK, INC.
Other - Org Name:MONUMENT HEALTH LEAD-DEADWOOD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CUSTER LD-DWD MARKETS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-755-8094
Mailing Address - Street 1:PO BOX 860013
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0013
Mailing Address - Country:US
Mailing Address - Phone:605-717-6431
Mailing Address - Fax:605-719-6163
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:605-719-6163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONUMENT HEALTH NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-04
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
SD10535282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1720214737OtherNPI NUMBER
SD214518OtherADCES CERTIFICATE