Provider Demographics
NPI:1083693584
Name:TIESZEN MEMORIAL HOME INC
Entity Type:Organization
Organization Name:TIESZEN MEMORIAL HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:I
Authorized Official - Last Name:ENGBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-648-3611
Mailing Address - Street 1:312 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SD
Mailing Address - Zip Code:57043-2011
Mailing Address - Country:US
Mailing Address - Phone:605-648-3611
Mailing Address - Fax:605-648-3363
Practice Address - Street 1:312 E STATE ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SD
Practice Address - Zip Code:57043-2011
Practice Address - Country:US
Practice Address - Phone:605-648-3611
Practice Address - Fax:605-648-3363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD41974310400000X
SD10647314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0160650Medicaid
SD435069Medicare ID - Type Unspecified