Provider Demographics
NPI:1508849761
Name:PRAIRIE VILLA
Entity Type:Organization
Organization Name:PRAIRIE VILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-724-2159
Mailing Address - Street 1:1309 BRADDOCK ST
Mailing Address - Street 2:
Mailing Address - City:ARMOUR
Mailing Address - State:SD
Mailing Address - Zip Code:57313-2102
Mailing Address - Country:US
Mailing Address - Phone:605-724-2159
Mailing Address - Fax:605-724-2310
Practice Address - Street 1:1309 BRADDOCK ST
Practice Address - Street 2:
Practice Address - City:ARMOUR
Practice Address - State:SD
Practice Address - Zip Code:57313-2102
Practice Address - Country:US
Practice Address - Phone:605-724-2159
Practice Address - Fax:605-724-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570570Medicaid