Provider Demographics
NPI:1508988130
Name:LIFEQUEST
Entity Type:Organization
Organization Name:LIFEQUEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-996-2032
Mailing Address - Street 1:804 N MENTZER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2130
Mailing Address - Country:US
Mailing Address - Phone:605-996-2032
Mailing Address - Fax:605-996-0972
Practice Address - Street 1:804 N MENTZER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2130
Practice Address - Country:US
Practice Address - Phone:605-996-2032
Practice Address - Fax:605-996-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5180030Medicaid