Provider Demographics
NPI:1093924490
Name:WAKONDA SUPERVISED LIVING INC
Entity Type:Organization
Organization Name:WAKONDA SUPERVISED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMANUS
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11048310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9572190Medicaid