Basic Information
| Provider Information | |||||||||
| NPI: | 1003073917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPT OF VETERAN AFFAIRS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CWT-438 SD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 W 22ND ST | ||||||||
| Address2: | 116A | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053363632 | ||||||||
| FaxNumber: | 6053336804 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W 22ND ST SF VA MEDICAL CENTER | ||||||||
| Address2: | 116A | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053363230 | ||||||||
| FaxNumber: | 6053336804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SE | ||||||||
| AuthorizedOfficialTelephone: | 6053363230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 283Q00000X | 01 | SD | SF VA MEDICAL CENTER | OTHER |