Provider Demographics
NPI:1659544807
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-775-2621
Mailing Address - Street 1:809 JACKSON ST
Mailing Address - Street 2:PO BOX 319
Mailing Address - City:BURKE
Mailing Address - State:SD
Mailing Address - Zip Code:57523-0319
Mailing Address - Country:US
Mailing Address - Phone:605-775-2621
Mailing Address - Fax:
Practice Address - Street 1:809 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:SD
Practice Address - Zip Code:57523-0319
Practice Address - Country:US
Practice Address - Phone:605-775-2621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10530251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9550220Medicaid