Provider Demographics
NPI:1689863839
Name:BLACK HILLS REGIONAL EYE INSTITUTE, LLP
Entity type:Organization
Organization Name:BLACK HILLS REGIONAL EYE INSTITUTE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:605-341-2000
Mailing Address - Street 1:2800 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7374
Mailing Address - Country:US
Mailing Address - Phone:605-341-2000
Mailing Address - Fax:605-719-3211
Practice Address - Street 1:3100 WEST LAKEWOOD ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-4135
Practice Address - Country:US
Practice Address - Phone:307-686-0883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116328700Medicaid
WY309022Medicare PIN