Provider Demographics
NPI:1548391022
Name:SOUTH DAKOTA DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:SOUTH DAKOTA DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TEAGAN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BRULEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:605-472-4231
Mailing Address - Street 1:17267 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57469-1001
Mailing Address - Country:US
Mailing Address - Phone:605-472-2400
Mailing Address - Fax:605-472-4457
Practice Address - Street 1:17267 W 3RD ST
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:SD
Practice Address - Zip Code:57469-1001
Practice Address - Country:US
Practice Address - Phone:605-472-4231
Practice Address - Fax:605-472-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0169020Medicaid
SD0169020Medicaid