Provider Demographics
NPI:1730275165
Name:FOOTHILLS FAMILY CLINIC
Entity type:Organization
Organization Name:FOOTHILLS FAMILY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-718-7625
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:SD
Mailing Address - Zip Code:57718
Mailing Address - Country:US
Mailing Address - Phone:605-718-7625
Mailing Address - Fax:605-718-7627
Practice Address - Street 1:8075 STAGESTOP RD
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:SD
Practice Address - Zip Code:57718
Practice Address - Country:US
Practice Address - Phone:605-718-7625
Practice Address - Fax:605-718-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS1005S1Medicare ID - Type Unspecified