Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 409 4th St, Wilmot, South Dakota |
Authorized Official Name and Position | David Flicek (PRESIDENT/CEO) |
Authorized Official Contact | 6053227916 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
409 4th St Wilmot SD 57279-2214 Ph: (605) 938-4351 | 409 4th St Wilmot SD 57279-2214 Ph: (605) 938-4351 |
NPI Number | 1770680787 |
---|---|
Provider Enumeration Date | 09/20/2006 |
Last Update Date | 09/10/2020 |
Medicare PECOS PAC ID | 0345157103 |
---|---|
Medicare Enrollment ID | O20100423000334 |
Identifier | Type | State | Issuer |
---|---|---|---|
1770680787 | NPI | - | NPPES |
5300010 | Medicaid | SD | |
43D0901649 | Other | SD | CLIA # |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QR1300X | Clinic/center - Rural Health | (* (Not Available)) | Primary |
363L00000X | Nurse Practitioner | (* (Not Available)) | Secondary |