Basic Information
Provider Information | |||||||||
NPI: | 1184174781 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONUMENT HEALTH HOME PLUS HOME INFUSION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 860013 | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554860013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057557649 | ||||||||
FaxNumber: | 6057557884 | ||||||||
Practice Location | |||||||||
Address1: | 224 ELK ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | RAPID CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 577017359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057551150 | ||||||||
FaxNumber: | 6057551151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2016 | ||||||||
LastUpdateDate: | 08/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TILLES | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT MONUMENT HEALTH HOME PLUS | ||||||||
AuthorizedOfficialTelephone: | 6055191179 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X |   |   | Y |   | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
No ID Information.