Provider Demographics
NPI:1023878915
Name:SPECIALTY CLINIC OF SIOUX CITY, LLC
Entity type:Organization
Organization Name:SPECIALTY CLINIC OF SIOUX CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:605-553-6458
Mailing Address - Street 1:166 SADDLEBROOK CT
Mailing Address - Street 2:
Mailing Address - City:NORTH SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5443
Mailing Address - Country:US
Mailing Address - Phone:605-553-6458
Mailing Address - Fax:
Practice Address - Street 1:400 BAYHILL CIR
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5092
Practice Address - Country:US
Practice Address - Phone:605-553-6458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty