Provider Demographics
NPI:1164602462
Name:CLARE JOHNSON
Entity Type:Organization
Organization Name:CLARE JOHNSON
Other - Org Name:THE HOMESTEAD ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER ADM
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER ADM
Authorized Official - Phone:605-785-3310
Mailing Address - Street 1:802 1ST AVE S
Mailing Address - Street 2:PO BOX 229
Mailing Address - City:LAKE NORDEN
Mailing Address - State:SD
Mailing Address - Zip Code:57248-0229
Mailing Address - Country:US
Mailing Address - Phone:605-785-3310
Mailing Address - Fax:605-785-3310
Practice Address - Street 1:802 1ST AVE S
Practice Address - Street 2:
Practice Address - City:LAKE NORDEN
Practice Address - State:SD
Practice Address - Zip Code:57248-0229
Practice Address - Country:US
Practice Address - Phone:605-785-3310
Practice Address - Fax:605-785-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11072310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility