Basic Information
| Provider Information | |||||||||
| NPI: | 1558459073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL HEALTH NETWORK INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGIONAL HEALTH CUSTER HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860013 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056732229 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1039 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CUSTER | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056732229 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | PAULETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6057559138 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 47660 | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 47660 | 01 | SD | LICENSE | OTHER | 5800240 | 05 | SD | MEDICAID |