Basic Information
| Provider Information | |||||||||
| NPI: | 1538149455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF JERAULD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055391201 | ||||||||
| FaxNumber: | 6055394580 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055391201 | ||||||||
| FaxNumber: | 6055394580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 02/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | KAYLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6055391201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | S99040 | 01 | SD | MEDICARE PROVIDER# | OTHER | 0099040 | 01 | SD | BC BS | OTHER | 9000530 | 05 | SD | MEDICAID |