Provider Demographics
NPI:1831140680
Name:CASTLEWOOD ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:CASTLEWOOD ASSISTED LIVING, LLC
Other - Org Name:CASTLEWOOD ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HALVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-940-4701
Mailing Address - Street 1:PO BOX 1202
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57101
Mailing Address - Country:US
Mailing Address - Phone:605-338-8896
Mailing Address - Fax:605-575-0997
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CASTLEWOOD
Practice Address - State:SD
Practice Address - Zip Code:57223
Practice Address - Country:US
Practice Address - Phone:605-793-2234
Practice Address - Fax:605-793-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD40126310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9572422Medicaid