Provider Demographics
NPI:1962858985
Name:LAC CASTOR WELLNESS, LLC
Entity type:Organization
Organization Name:LAC CASTOR WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUSKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CNP
Authorized Official - Phone:605-415-1616
Mailing Address - Street 1:3213 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2314
Mailing Address - Country:US
Mailing Address - Phone:605-415-1616
Mailing Address - Fax:
Practice Address - Street 1:3213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2314
Practice Address - Country:US
Practice Address - Phone:605-415-1616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001043363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty