Provider Demographics
NPI:1588760631
Name:PRAIRIE INNOVATIONS, LLC
Entity type:Organization
Organization Name:PRAIRIE INNOVATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WETENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-229-6850
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-0887
Mailing Address - Country:US
Mailing Address - Phone:605-229-6850
Mailing Address - Fax:605-225-1417
Practice Address - Street 1:902 S JAY ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-6150
Practice Address - Country:US
Practice Address - Phone:605-229-6850
Practice Address - Fax:605-225-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD11014231OtherSD DEPT OF SOCIAL SERVICE
SD9560550Medicaid