Provider Demographics
NPI:1629059761
Name:MENNO-OLIVET RETIREMENT HOME INC
Entity Type:Organization
Organization Name:MENNO-OLIVET RETIREMENT HOME INC
Other - Org Name:MENNO-OLIVET CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-387-5139
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:MENNO
Mailing Address - State:SD
Mailing Address - Zip Code:57045-0487
Mailing Address - Country:US
Mailing Address - Phone:605-387-5139
Mailing Address - Fax:605-387-2441
Practice Address - Street 1:402 SOUTH PINE STREET
Practice Address - Street 2:
Practice Address - City:MENNO
Practice Address - State:SD
Practice Address - Zip Code:57045-0487
Practice Address - Country:US
Practice Address - Phone:605-387-5139
Practice Address - Fax:605-387-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10648314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0160260Medicaid
SD0160260Medicaid