Basic Information
| Provider Information | |||||||||
| NPI: | 1174569669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE LAKES HEALTH CARE SYSTEMS INC. | ||||||||
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| OtherOrganizationName: | PRAIRIE LAKES KIDNEY DIALYSIS SISSETON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 9TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572011548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058827000 | ||||||||
| FaxNumber: | 6058827607 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 LAKE TRAVERSE DR | ||||||||
| Address2: | |||||||||
| City: | SISSETON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058827000 | ||||||||
| FaxNumber: | 6058827607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | POPP | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | ADAM | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6058827718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.