Basic Information
Provider Information | |||||||||
NPI: | 1114942364 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRAIRIE LAKES HEALTH CARE SYSTEMS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 9TH AVE NW | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | SD | ||||||||
PostalCode: | 572011548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6058827000 | ||||||||
FaxNumber: | 6058827607 | ||||||||
Practice Location | |||||||||
Address1: | 401 9TH AVE NW | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | SD | ||||||||
PostalCode: | 572011548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6058827000 | ||||||||
FaxNumber: | 6058827607 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POPP | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: | ADAM | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6058827718 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 10572 | SD | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 159920 | 05 | SD |   | MEDICAID |