Basic Information
Provider Information | |||||||||
NPI: | 1063717411 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BIG STONE THERAPIES WATERTOWN, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BST WATERTOWN LLC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 CROSS ST | ||||||||
Address2: |   | ||||||||
City: | BIG STONE CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 572168237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6055411140 | ||||||||
FaxNumber: | 6055410109 | ||||||||
Practice Location | |||||||||
Address1: | 8 5TH ST SE | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | SD | ||||||||
PostalCode: | 572013713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057535400 | ||||||||
FaxNumber: | 6057536208 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2011 | ||||||||
LastUpdateDate: | 05/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ACKERMAN | ||||||||
AuthorizedOfficialFirstName: | ANGIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE AND ADMIN | ||||||||
AuthorizedOfficialTelephone: | 6055411144 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 261QH0700X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.