Basic Information
| Provider Information | |||||||||
| NPI: | 1952647760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TINDALL | ||||||||
| FirstName: | KLANCY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | KLANCY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 142 MAPLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GWINNER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580404200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016809572 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1311 VANDER HORCK AVENUE | ||||||||
| Address2: | |||||||||
| City: | BRITTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 574300939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054482251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2012 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29OA | SD | Y | Other Service Providers | Specialist |
No ID Information.