Basic Information
| Provider Information | |||||||||
| NPI: | 1962004523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLSKOPF | ||||||||
| FirstName: | MASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 918 SAINT JOE ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154505025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1420 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057178595 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 0742 | SD | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.