Provider Demographics
NPI:1699069567
Name:BLACK HILLS OPTOMETRY LLC
Entity type:Organization
Organization Name:BLACK HILLS OPTOMETRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTENHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-718-5888
Mailing Address - Street 1:2932 TOMAHAWK DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4250
Mailing Address - Country:US
Mailing Address - Phone:605-718-5888
Mailing Address - Fax:605-718-5888
Practice Address - Street 1:318 MOUNT RUSHMORE RD
Practice Address - Street 2:SUITE A
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2769
Practice Address - Country:US
Practice Address - Phone:605-718-5888
Practice Address - Fax:605-718-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty