Provider Demographics
NPI:1063553287
Name:BLACK HILLS ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:BLACK HILLS ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CERTIFIED ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:605-341-8577
Mailing Address - Street 1:3639 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4637
Mailing Address - Country:US
Mailing Address - Phone:308-632-4641
Mailing Address - Fax:308-632-6247
Practice Address - Street 1:1802 ELM AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3846
Practice Address - Country:US
Practice Address - Phone:605-341-8577
Practice Address - Fax:605-341-7656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD53-001-E-ST1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9151810Medicaid
SD9151810Medicaid