Basic Information
| Provider Information | |||||||||
| NPI: | 1740355635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. BENEDICT HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AVERA ST. BENEDICT CRHC, TRIPP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W GLYNN DR | ||||||||
| Address2: | |||||||||
| City: | PARKSTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573669605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059283311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TRIPP | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573762109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059357211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | LINDSAY | ||||||||
| AuthorizedOfficialMiddleName: | RAE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6059357211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 5340070 | 05 | SD | MEDICAID | 4997658 | 01 | SD | WELLMARK TRIPP CLINIC | OTHER | 5340340 | 05 | SD | MEDICAID |