Provider Demographics
NPI:1952591000
Name:CASCADE INTEGRATIVE MEDICINE OF SOUTH DAKOTA, P.C.
Entity type:Organization
Organization Name:CASCADE INTEGRATIVE MEDICINE OF SOUTH DAKOTA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:VERN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYS ASST
Authorized Official - Phone:605-745-5102
Mailing Address - Street 1:1501 HIGHWAY 18 BYP
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-9600
Mailing Address - Country:US
Mailing Address - Phone:605-745-5102
Mailing Address - Fax:605-745-6707
Practice Address - Street 1:1501 HIGHWAY 18 BYP
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-9600
Practice Address - Country:US
Practice Address - Phone:605-745-5102
Practice Address - Fax:605-745-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
SD0177261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR94179Medicare UPIN