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709 4th St Se Lake Preston SD 57249-2116 | |
(605) 847-4484 | |
Not Available |
Full Name | |
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Speciality | Clinic/Center |
Location | 709 4th St Se, Lake Preston, South Dakota |
Authorized Official Name and Position | John Mengenhausen (CEO) |
Authorized Official Contact | 6057724525 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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709 4th St Se Lake Preston SD 57249-2116 Ph: (605) 847-4484 | 709 4th St Se Lake Preston SD 57249-2116 Ph: (605) 847-4484 |
NPI Number | 1629181904 |
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Provider Enumeration Date | 08/17/2006 |
Last Update Date | 06/23/2008 |
Medicare PECOS PAC ID | 8921997933 |
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Medicare Enrollment ID | O20081008000286 |
Identifier | Type | State | Issuer |
---|---|---|---|
1629181904 | NPI | - | NPPES |
5350030 | Medicaid | SD |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |