Provider Demographics
NPI:1912073834
Name:BLACK HILLS REGIONAL EYE INSTITUTE
Entity Type:Organization
Organization Name:BLACK HILLS REGIONAL EYE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUDRALA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:605-341-2000
Mailing Address - Street 1:2800 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7374
Mailing Address - Country:US
Mailing Address - Phone:605-341-2000
Mailing Address - Fax:605-341-0278
Practice Address - Street 1:2800 3RD ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7374
Practice Address - Country:US
Practice Address - Phone:605-341-2000
Practice Address - Fax:605-341-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD100152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200655Medicaid
SDT66591Medicare UPIN
SD41484Medicare ID - Type Unspecified