Provider Demographics
NPI:1033147384
Name:COMMUNITY MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL INC
Other - Org Name:BONESTEEL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREY
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:605-775-2621
Mailing Address - Street 1:314 MELLETTE STREET
Mailing Address - Street 2:
Mailing Address - City:BONESTEEL
Mailing Address - State:SD
Mailing Address - Zip Code:57317-0342
Mailing Address - Country:US
Mailing Address - Phone:605-654-9021
Mailing Address - Fax:
Practice Address - Street 1:314 MELLETTE STREET
Practice Address - Street 2:
Practice Address - City:BONESTEEL
Practice Address - State:SD
Practice Address - Zip Code:57317-0342
Practice Address - Country:US
Practice Address - Phone:605-654-9021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5340240Medicaid
SD433422Medicare Oscar/Certification