Provider Demographics
NPI:1225349814
Name:MENNO-OLIVET RETIREMENT HOME INC
Entity Type:Organization
Organization Name:MENNO-OLIVET RETIREMENT HOME INC
Other - Org Name:MENNO-OLIVET ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-387-5139
Mailing Address - Street 1:402 SOUTH PINE STREET
Mailing Address - Street 2:
Mailing Address - City:MENNO
Mailing Address - State:SD
Mailing Address - Zip Code:57045-0487
Mailing Address - Country:US
Mailing Address - Phone:605-387-5139
Mailing Address - Fax:605-387-2441
Practice Address - Street 1:402 SOUTH PINE STREET
Practice Address - Street 2:
Practice Address - City:MENNO
Practice Address - State:SD
Practice Address - Zip Code:57045-0487
Practice Address - Country:US
Practice Address - Phone:605-387-5139
Practice Address - Fax:605-387-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD59462310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570230Medicaid
SD435113Medicare Oscar/Certification