Basic Information
| Provider Information | |||||||||
| NPI: | 1669508677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF THE BLACK HILLS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RAPID CITY COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | 6057218853 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | 6057218853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | TRIHART | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6057218939 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 5350060 | 05 | SD | MEDICAID | SD04129S3001 | 01 | SD | MEDICARE PART B | OTHER | SD04129S3000 | 01 | SD | MEDICARE PART B | OTHER |