Basic Information
Provider Information | |||||||||
NPI: | 1922453075 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONUMENT HEALTH NETWORK, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONUMENT HEALTH SPEARFISH CLINIC, NORTH 10TH STREET | ||||||||
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: | 6057178595 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1420 N 10TH ST | ||||||||
Address2: |   | ||||||||
City: | SPEARFISH | ||||||||
State: | SD | ||||||||
PostalCode: | 57783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057478595 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2016 | ||||||||
LastUpdateDate: | 02/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WORSLEY | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT SPEARFISH HOSPITAL | ||||||||
AuthorizedOfficialTelephone: | 6056444091 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONUMENT HEALTH NETWORK, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 214518 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 214518 | 01 | SD | DIABETES EDUCATION RECOGNITION PROGRAM | OTHER |