Provider Demographics
NPI:1063475812
Name:BELLE FOURCHE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BELLE FOURCHE HEALTHCARE, LLC
Other - Org Name:BELLE FOURCHE HEALTHCARE COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOERBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-873-7907
Mailing Address - Street 1:2200 - 13TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-2215
Mailing Address - Country:US
Mailing Address - Phone:605-892-3331
Mailing Address - Fax:605-723-0204
Practice Address - Street 1:2200 - 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2215
Practice Address - Country:US
Practice Address - Phone:605-892-3331
Practice Address - Fax:605-723-0204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELCOV HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-11
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10594314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0150203Medicaid
SD0150203Medicaid