Provider Demographics
NPI:1235223942
Name:SALEM MENNONITE HOME FOR THE AGED
Entity Type:Organization
Organization Name:SALEM MENNONITE HOME FOR THE AGED
Other - Org Name:SALEM MENNONITE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-925-4994
Mailing Address - Street 1:106 W. 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:FREEMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57029-2319
Mailing Address - Country:US
Mailing Address - Phone:605-925-4994
Mailing Address - Fax:605-925-4764
Practice Address - Street 1:106 W. 7TH STREET
Practice Address - Street 2:
Practice Address - City:FREEMAN
Practice Address - State:SD
Practice Address - Zip Code:57029-2319
Practice Address - Country:US
Practice Address - Phone:605-925-4994
Practice Address - Fax:605-925-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10622310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9566630Medicaid
SD957133Medicaid