Provider Demographics
NPI:1104559814
Name:MAVERICK HEALTH CARE, PROF. LLC
Entity type:Organization
Organization Name:MAVERICK HEALTH CARE, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / OWNER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KUEHLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-531-4028
Mailing Address - Street 1:2625 MAVERICK CT
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-9702
Mailing Address - Country:US
Mailing Address - Phone:815-531-4028
Mailing Address - Fax:
Practice Address - Street 1:2200 13TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2215
Practice Address - Country:US
Practice Address - Phone:605-892-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104559814OtherFAMILY MEDICINE