Provider Demographics
NPI:1124586037
Name:VISTA CARE SOUTH DAKOTA, LLC
Entity Type:Organization
Organization Name:VISTA CARE SOUTH DAKOTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-694-1102
Mailing Address - Street 1:708 ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4060
Mailing Address - Country:US
Mailing Address - Phone:920-694-1102
Mailing Address - Fax:920-694-4685
Practice Address - Street 1:708 ERIE AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4060
Practice Address - Country:US
Practice Address - Phone:920-694-1102
Practice Address - Fax:920-694-4685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No253Z00000XAgenciesIn Home Supportive Care