Provider Demographics
NPI:1487990248
Name:BLACK HILLS PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:BLACK HILLS PEDIATRIC THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PT, DPT - OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:605-222-3773
Mailing Address - Street 1:505 KANSAS CITY ST.
Mailing Address - Street 2:SUITE #3
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3673
Mailing Address - Country:US
Mailing Address - Phone:605-222-3773
Mailing Address - Fax:605-791-0631
Practice Address - Street 1:505 KANSAS CITY ST.
Practice Address - Street 2:SUITE #3
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3673
Practice Address - Country:US
Practice Address - Phone:605-222-3773
Practice Address - Fax:605-791-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty