Provider Demographics
NPI:1134188600
Name:DAKOTA VISION CENTER, LLC
Entity type:Organization
Organization Name:DAKOTA VISION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:ANKRUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-361-1680
Mailing Address - Street 1:5012 S BUR OAK PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2228
Mailing Address - Country:US
Mailing Address - Phone:605-361-1680
Mailing Address - Fax:605-361-1590
Practice Address - Street 1:5012 S BUR OAK PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2228
Practice Address - Country:US
Practice Address - Phone:605-361-1680
Practice Address - Fax:605-361-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT-473152W00000X
SDT-462152W00000X
SDT-155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202133Medicaid
SD9202072Medicaid
SD9202392Medicaid
SD0877020001Medicare NSC
SD9202392Medicaid
SDS100684Medicare PIN
SDU-26182Medicare UPIN
SDT-66671Medicare UPIN