Provider Demographics
NPI:1619010543
Name:CHAMBERLAIN ACADEMY
Entity Type:Organization
Organization Name:CHAMBERLAIN ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHREIBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-234-5525
Mailing Address - Street 1:211 W 16TH AVE
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:CHAMBERLAIN
Mailing Address - State:SD
Mailing Address - Zip Code:57325-0367
Mailing Address - Country:US
Mailing Address - Phone:605-234-5525
Mailing Address - Fax:605-234-6889
Practice Address - Street 1:211 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERLAIN
Practice Address - State:SD
Practice Address - Zip Code:57325-0367
Practice Address - Country:US
Practice Address - Phone:605-234-5525
Practice Address - Fax:605-234-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR 105322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5160750Medicaid