Provider Demographics
NPI:1013475011
Name:PENDELTON HOUSE ASSISTED LIVING
Entity Type:Organization
Organization Name:PENDELTON HOUSE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DESHAWN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PENDELTON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:217-670-7948
Mailing Address - Street 1:220 N CENETER AVE
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301
Mailing Address - Country:US
Mailing Address - Phone:217-670-7948
Mailing Address - Fax:
Practice Address - Street 1:220 N CENETER AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301
Practice Address - Country:US
Practice Address - Phone:217-670-7948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility