Provider Demographics
NPI:1508635772
Name:PRAIRIE VIEW MEDICAL, PROF. LLC
Entity Type:Organization
Organization Name:PRAIRIE VIEW MEDICAL, PROF. LLC
Other - Org Name:PRAIRIE VIEW MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-693-7862
Mailing Address - Street 1:3405 6TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-4401
Mailing Address - Country:US
Mailing Address - Phone:605-693-7862
Mailing Address - Fax:605-693-7900
Practice Address - Street 1:3405 6TH ST STE 5
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-4401
Practice Address - Country:US
Practice Address - Phone:605-695-6712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-28
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care