Provider Demographics
NPI:1003803818
Name:WAKONDA HERITAGE MANOR.
Entity Type:Organization
Organization Name:WAKONDA HERITAGE MANOR.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-267-2081
Mailing Address - Street 1:515 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:WAKONDA
Mailing Address - State:SD
Mailing Address - Zip Code:57073-2013
Mailing Address - Country:US
Mailing Address - Phone:605-267-2081
Mailing Address - Fax:605-267-2690
Practice Address - Street 1:515 OHIO ST
Practice Address - Street 2:
Practice Address - City:WAKONDA
Practice Address - State:SD
Practice Address - Zip Code:57073-2013
Practice Address - Country:US
Practice Address - Phone:605-267-2081
Practice Address - Fax:605-267-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10701314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0160590Medicaid
SD0160590Medicaid