Provider Demographics
NPI:1962004523
Name:WELLSKOPF, MASON
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:WELLSKOPF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 SAINT JOE ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1729
Mailing Address - Country:US
Mailing Address - Phone:715-450-5025
Mailing Address - Fax:
Practice Address - Street 1:1420 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-717-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered