|
| |
|
11 East 4th Street Lemmon SD 57638-0447 | |
| (605) 374-3862 | |
| (605) 374-3864 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 11 East 4th Street, Lemmon, South Dakota |
| Authorized Official Name and Position | Laurie Berg (BILLING MANAGER) |
| Authorized Official Contact | 6053743862 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
11 East 4th St. P.o. Box 447 Lemmon SD 57638-0447 Ph: (605) 374-3862 | 11 East 4th Street Lemmon SD 57638-0447 Ph: (605) 374-3862 |
| NPI Number | 1811001985 |
|---|---|
| Provider Enumeration Date | 08/18/2006 |
| Last Update Date | 01/08/2024 |
| Certification Date | 01/08/2024 |
| Medicare PECOS PAC ID | 7315380185 |
|---|---|
| Medicare Enrollment ID | O20240208002045 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811001985 | NPI | - | NPPES |
| 0003226 | Other | SD | BCBS GROUP PROVIDER # |
| 1234567 | Other | SD | JASON LILLICH |
| 4994184 | Other | SD | MIKKI KENNEDY-HAINES ID# |
| Provider Name | Jacquelyn Hedstrom |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1891206215 PECOS PAC ID: 9032476973 Enrollment ID: I20240224000670 |
| Provider Name | Jason Lillich |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1821593005 PECOS PAC ID: 3577906346 Enrollment ID: I20240620000640 |