1730238973 NPI number — EASTERN STAR HOME OF SOUTH DAKOTA INC

Table of content: (NPI 1730238973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730238973 NPI number — EASTERN STAR HOME OF SOUTH DAKOTA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN STAR HOME OF SOUTH DAKOTA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730238973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDFIELD
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57469-0150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-472-0658
Provider Business Mailing Address Fax Number:
605-472-3590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 W 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDFIELD
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57469-1522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-472-0658
Provider Business Practice Location Address Fax Number:
605-472-3590
Provider Enumeration Date:
01/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RICE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
605-472-0658

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  10670 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0150120 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".