Provider Demographics
NPI:1699204313
Name:SIOUX FALLS PRIMARY HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:SIOUX FALLS PRIMARY HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AMON
Authorized Official - Middle Name:E
Authorized Official - Last Name:ABOUA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:605-335-0023
Mailing Address - Street 1:201 N MINNESOTA AVE STE 101L
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6044
Mailing Address - Country:US
Mailing Address - Phone:605-335-0023
Mailing Address - Fax:605-853-7155
Practice Address - Street 1:201 N MINNESOTA AVE STE 101L
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104
Practice Address - Country:US
Practice Address - Phone:605-335-0023
Practice Address - Fax:605-853-7155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1699204313Medicaid