Provider Demographics
NPI:1093204398
Name:CHANNEL ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:CHANNEL ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-520-5469
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:SD
Mailing Address - Zip Code:57221-0278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:SD
Practice Address - Zip Code:57221-2055
Practice Address - Country:US
Practice Address - Phone:605-628-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD41812310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility