1871600759 NPI number — ROSHOLT COUNTRY INN

Table of content: (NPI 1871600759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871600759 NPI number — ROSHOLT COUNTRY INN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSHOLT COUNTRY INN
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:
COUNTRYSIDE INN ASSISTED LIVING & MEMORY CARE
Provider Other Organization Name Type Code:
3
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:
1871600759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 PRAIRIE AVE
Provider Second Line Business Mailing Address:
PO BOX 218
Provider Business Mailing Address City Name:
ROSHOLT
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57260-0218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-537-4588
Provider Business Mailing Address Fax Number:
605-537-4890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSHOLT
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57260-0218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-537-4588
Provider Business Practice Location Address Fax Number:
605-537-4890
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANDEPUTTE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER - OPERATOR
Authorized Official Telephone Number:
605-537-4588

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  53737 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 311500000X , with the licence number: 53737 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 9570820 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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