Provider Demographics
NPI:1255375556
Name:ST. LUKE'S HEALTH RESOURCES
Entity type:Organization
Organization Name:ST. LUKE'S HEALTH RESOURCES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-279-3934
Mailing Address - Street 1:2720 STONE PARK BLVD
Mailing Address - Street 2:ROOM 629
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3734
Mailing Address - Country:US
Mailing Address - Phone:712-279-3380
Mailing Address - Fax:712-279-7015
Practice Address - Street 1:224 N DERBY LN
Practice Address - Street 2:
Practice Address - City:NORTH SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:57049-3016
Practice Address - Country:US
Practice Address - Phone:605-232-6422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD40560Medicare ID - Type Unspecified